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Fiske  Fund  Prize  Dissertation.      No.  LIII. 


The  Classification   and  Treatment 

of  Diseases  Commonly  Known 

as   Rheumatism. 


MOTTO: 
"Vero  nihil  verius." 


BY 

FRANK  E.  PECKHAM,  M.  D., 
Providence,  R.  I. 


PROVIDENCE: 

Snow  &  Farnham  Company,  Printers. 
1910. 


r"THE  Trustees  of  the  Fiske  Fund,  at  the  annual  meeting  of  the 
*  Rhode  Island  Medical  Society,  held  at  Providence,  May  31,  1910, 
announced  that  they  had  awarded  a  premium  of  two  hundred  ($200) 
to  an  essay  on  "  The  Classification  and  Treatment  of  Diseases 
Commonly  Known  as  Rheumatism,"   bearing  the  motto  : 

"Vero  nihil  verius." 


The    author    was    found    to    be     FRANK    E.    PECKHAM,    M.  D., 
of  Providence,  R.  I. 

Dr.   EUGENE   KINGMAN,    Providence. 

Dr.    A.  A.   MANN,    Central  Falls. 

Dr.    FREDERICK  T.  ROGERS,  Providence. 

Trustees. 

HALSEY  DkWOLF,  M.  D.,  Providence, 

Secretary  of  the  Trustees. 


The  Classification  and  Treatment  of  Diseases 
Commonly  Known  as  Rheumatism. 


A  classification  must  be  founded  on  some  logical 
basis,  for  example  an  etiological  or  a  pathological,  then 
the  treatment  can  be  applied  much  more  accurately 
and  with  a  much  greater  prospect  of  permanent  cure. 
The  diseases  commonly  known  as  rheumatism  are  those 
associated  with  pain  about  the  joints  or  muscles. 
When  in  the  muscles,  it  is  commonly  called  muscular 
rheumatism ;  when  in  the  back,  lumbago.  Sciatic 
rheumatism,  used  synonymously  with  sciatic  neuritis, 
are  not  uncommon  terms.  When  the  joints  are 
involved,  the  term  rheumatism,  chronic  rheumatism, 
gout,  and  rheumatic  gout  are  very  common.  To  re- 
duce all  these  terms  to  something  tangible  in  the  way 
of  classification,  has  been  a  tremendous  undertaking 
and  has  been  attempted  by  many  men.  Most  of  these 
attempts  have  resulted  in  schemes  so  complex  and 
cumbersome  as  to  render  them  useless.  A  scheme  to 
be  useful  must  be  as  simple  as  possible  and  readily 
applied  clinically  with  knowledge  which  may  be  com- 
paratively easily  obtained.  A  careful  history  of  the 
case,  a  careful  history  of  the  patient's  troubles  which 


6  THE    CLASSIFICATION    AND    TREATMENT    OF 

might  have  any  bearing,  a  careful  physical  examina- 
tion not  only  of  the  particular  joints  or  areas  of  pain 
but  of  the  physiological  processes  in  general, — that  is, 
bowels,  urine,  liver ;  also  an  examination  for  flexibility 
of  spine  and  for  tender  spots  anywhere  up  or  down  the 
spine  and  for  any  slight  deviation  of  vertebrae,  an  ex- 
amination of  the  sacro-iliac  joints,  and  range  of  motion 
of  legs  (with  knee  extended)  on  the  ilia,  and  an  ex- 
amination of  joints  other  than  those  complained  of. 
Add  to  this  a  careful  X-ray  study  and  outside  of  some 
unusual  and  border  line  conditions,  the  case  may  usually 
be  classified. 

The  many  classifications  offered  in  literature  might 
all  be  enumerated  but  such  a  waste  of  time  is  hardly 
necessary  in  the  present  stage  of  the  development  of 
the  subject.  There  are  a  very  small  number  of  types 
of  these  joint  conditions  which  ordinarily  may  be  dif- 
ferentiated without  much  difficulty.  There  are  the 
villous  arthritis,  atrophic  arthritis,  hypertrophic  arthri- 
tis, infectious  arthritis  and  gout.  These  types  were  first 
described  by  Goldthwait.  Perhaps  the  most  logical  and 
convincing  way  to  demonstrate  this  may  be  to  describe 
a  typical  case  under  each  type,  in  this  way  showing 
why  it  is  placed  in  a  certain  class.  This  will  also  make 
the  treatment  seem  perfectly  logical  and  for  the  sake 
of  keeping  the  whole  thing  in  mind  as  an  entity,  the 
treatment  had  better  be  placed  after  such  description. 

The  simplest  form  of  joint  trouble  which  has  formerly 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.  7 

fallen  under  the  term  rheumatism  occurs  oftenest  in  the 
knee  joints.  The  patient  complains  of  some  pain  in  the 
knees,  some  stiffness  in  the  morning  especially  when 
first  getting  about  on  them  or  after  sitting  for  an  hour 
or  so,  and  is  very  apt  to  notice  a  grating  or  creaking 
on  going  up  or  down  stairs.  A  physical  examination 
reveals  a  "  boggy  "  knee  and  there  may  or  may  not  be 
a  small  amount  of  fluid  present,  usually  not.  There 
may  be  some  tenderness,  usually  on  the  inner  side  of 
the  joint.  If  the  patient  sits  in  a  chair  or  on  the  end 
of  the  examining  table  and  extends  and  flexes  the 
knees,  the  examining  hand  over  the  knees  detects  the 
grating  which  may  be  very  slight  or  very  marked.  If 
the  patient  stands  with  bare  feet,  they  are  usually  found 
to  be  pronated.  An  X-ray  picture  shows  the  bones  to 
be  normal  and  may  show  a  shadow  or  mottled  appear- 
ance just  below  the  patella  and  anteriorly  between  the 
fermur  and  tibia.  Such  a  knee,  if  it  should  be  opened, 
would  present,  instead  of  a  smooth  glistening  surface 
of  the  serous  membrane,  a  loose  tripe-like  condition. 
This  is  due  to  a  villous  growth  and  then  the  term  villous 
arthritis  may  be  used.  A  villous  arthritis  may  be 
present  in  most  any  type  of  joint  trouble,  as  an  infec- 
tion, or  even  in  tuberculosis ;  but  in  the  above  described 
condition,  it  exists  without  any  apparent  accompanying 
disease,  and  hence  is  one  type  of  joint  trouble  of  the 
so-called  rheumatic  group. 

This  condition  is  very  apt  to  be  accompanied  by  pro- 


8  THE   CLASSIFICATION    AND    TREATMENT    OF 

nated  feet  aud  is  mostly  seen  in  women.  It  is  not  so 
often  seen  in  men.  Women,  unless  inclined  to  be  thin 
or  of  a  spare  type,  are  apt  to  have  a  more  or  less  fleshy 
thigh.  It  may  be  observed  that  when  such  patients 
stand  with  inner  surface  of  knees  just  in  contact,  the 
inner  malleoli  will  be  separated,  some  slightly  and  some 
quite  markedly.  In  other  words,  there  is  some  degree 
of  knock  knee.  This  means  that  there  is  more  or  less 
of  a  strain  on  the  knee  joints,  this  strain  either  from 
pronated  feet  alone  or  in  conjunction  with  the  above 
condition  of  slight  knock  knee,  becoming  an  etiological 
factor.  A  demonstration  of  the  strain  of  a  knock  knee 
causing  a  villous  arthritis  has  occurred  in  a  very  marked 
manner  in  two  cases  coming  under  the  observation  of 
the  writer.  A  young  married  woman  had  only  one 
very  marked  knock  knee  and  the  knee  on  that  leg  had 
given  trouble  for  years,  at  times  swelling  up  and  becom- 
ing tender  and  painful.  Rest  and  local  applications 
had  quieted  it  each  time  but  it  gradually  became  en- 
larged so  that  it  was  never  normal  in  size  and  was  con- 
stantly grating  and  creaking  and  remaining  always 
tender  and  boggy  and  much  larger  than  the  other  knee. 
A  second  case  occurred  almost  exactly  like  it  in  a  man 
of  middle  age.  The  knee  had  given  him  more  and 
more  trouble  until  he  was  willing  to  do  anything  for 
relief.  Where  there  is  tenderness  and  pain  and  numb- 
ness around  the  knee  and  particularly  on  the  inner  side 
and  often  in  addition  about  the  ankle  and  anterior  part 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.  9 

of  the  foot,  there  will  usually  be  found  a  lax  condition 
of  the  sacro-iliac  joints  with  sufficient  tilting  of  the 
sacrum  or  ilium  to  impinge  on  the  lumbo  sacral  plexus, 
thus  interfering  with  the  nerve  supply  and  producing 
a  very  direct  effect  upon  the  knee  joints.  In  women 
with  saggy  abdominal  contents,  with  or  without  pen- 
dulous abdomen,  the  dragging  down  may  assist  to  pro- 
duce the  tilted  sacrum  or  ilium,  or  if  this  is  not  present, 
may  by  their  own  weight  interfere  with  the  large  nerve 
trunks  in  such  a  way  as  to  become  etiological.  The 
conventional  corset  alone  will  produce  just  this  condi- 
tion in  many  cases. 

The  treatment  of  this  condition  must  be  twofold. 
It  must  remove  the  causes  and  at  the  same  time  this 
thickened  boggy  condition  must  be  treated  so  as  to 
cause  its  complete  disappearance  if  possible.  First,  as 
to  the  causes.  The  pronated  feet  must  be  corrected 
by  being  placed  in  properly  shaped  shoes  and  thus  the 
foot  is  balanced.  This  balance  is  accomplished  by  pro- 
jecting the  inner  corner  of  the  heel  farther  forward, 
which  in  people  inclined  to  be  pretty  heavy  will  be 
sufficient,  but  in  lighter  weights  the  inner  side  of  the 
heel  must  be  raised  in  each  individual  case  to  com- 
pletely balance  the  foot.  Although  artificial  supports 
might  be  used  occasionally  it  would  not  ordinarily  be 
necessary.  This  balancing  would  also  correct  a  mild 
degree  of  knock  knee  but  not  an  exaggerated  case. 
The  markedly  pronated  foot  in   fleshy   women   would 


10  THE   CLASSIFICATION    AND    TREATMENT    OF 

call  for  a  heel  still  higher  and  still  farther  forward  on 
the  inside.  In  the  two  cases  cited  above,  where  there 
was  only  one  very  marked  knock  knee  and  also  a  very 
troublesome  and  painful  villous  arthritis,  I  advised  an 
osteotomy  for  the  correction  of  the  knock  knee  which 
was  so  evidently  the  cause.  In  the  lax  conditions  of 
the  sacro-iliac  joints,  the  tipping  of  the  sacrum  or  the 
ilium  may  first  be  corrected  by  manipulation.  An  effi- 
cient way  is  to  place  the  patient  on  an  examining  ta- 
ble full  length  face  down.  Then  by  pressing  down- 
ward with  one  hand  on  the  sacrum,  or  still  better  hav- 
ing an  assistant  hold  the  sacrum  by  pressing  strongly 
downward,  with  the  other  hand  or  with  both  hands 
firmly  grasping  the  thigh,  preferably  with  leg  flexed 
at  right  angle,  strongly  force  the  thigh  upward.  By 
bending  it  upward  several  times  the  joint  surfaces  are 
levered  into  better  apposition.  This  movement  may 
be  repeated  at  subsequent  visits  if  necessary.  In  wo- 
men the  corset  may  then  be  improved  by  the  addition 
of  a  belt  or  extension  so  adjusted  and  made  part  and 
parcel  of  the  corset  that  it  really  supports  the  abdomi- 
nal contents  holding  the  pelvic  girdle  more  firmly  to- 
gether. In  men  a  belt  may  be  made  which  accom- 
plishes the  same  purpose.  By  these  means  the  etio- 
logical factors  are  attacked  and  remedied. 

Lastly  the  joint  or  joints  demand  treatment  for  the 
local  condition  which,  as  described  above,  consists  of  a 
thickened     boggy     condition    of     serous     membrane* 


DISEASES    COMMONLY    KNOWN    AS    KHEUMATISM.         11 

These  villi  may  be  of  a  very  small  growth  or  they  may 
become  markedly  hypertrophied  forming  regular  tu- 
mors with  enlarged  ends  and  small  pedicles.  These 
larger  villi  may  undergo  fatty  degeneration  thus  form- 
ing fatty  tumors,  the  so-called  tumor  aborescens,  which 
are  mostly  apt  to  be  located  below  the  patella  and  be- 
neath the  ligamentum  patellae.  On  the  other  hand 
these  villi  may  undergo  calcification  at  the  ends  and 
then  the  pedicle  breaks  and  thus  are  formed  the  float- 
ing bodies.  It  is  necessary  to  describe  the  above  con- 
dition in  order  to  illustrate  treatment.  In  the  early 
stages  or  even  in  the  late  stage  with  secretion  of  fluid 
where  fatty  degeneration  or  calcification  has  not  taken 
place,  most  of  these  cases  are  curable  without  opera- 
tion. Such  knees  may  be  baked  in  the  special  ovens 
and  after  remaining  for  an  hour  may  be  thoroughly 
vibrated  using  the  hard  ball  and  beginning  with  gentle 
pressure.  After  a  few  treatments  the  pressure  may 
be  made  pretty  hard.  The  hot  air  bath  brings  fresh 
red  blood  to  these  parts  (hyperaemia).  Vibration  stim- 
ulates the  tissues  so  that  both  circulation  and  nerve 
supply  are  much  improved.  The  villous  condition 
slowly  contracts  and  becomes  less  and  less  spongy.  Hy- 
peraemia may  also  be  produced  by  the  Bier  method 
and  might  alone  be  of  benefit  in  some  cases,  but  is  not 
so  efficient  as  the  hot  air  and  vibration.  Vibration 
alone  is  beneficial  but  not  so  much  so  as  after  the  knee 
is  thoroughly  heated  through.     This  same  effect  can 


12  THE    CLASSIFICATION    AND    TREATMENT    OF 

be  produced  in  some  cases  by  the  so-called  Morton 
wave  current  followed  by  sparking  with  the  spark  se- 
lector, then  in  tender  joints  the  brush  discharge  may 
follow  on  this. 

The  wave  current  is  administered  by  applying  the 
circular  electrode  around  the  knees,  so  curved  as  to 
avoid  contact  with  the  patella  and  then  connected  to 
the  positive  pole  by  the  static  machine.  The  negative 
pole  is  grounded  by  a  special  chain  connected  to  a  steel 
rod  driven  into  the  earth.  The  patient  is  on  the  insu- 
lated table.  The  amount  of  current  forced  through 
the  tissues  is  regulated  by  the  spark  gap  between  the 
poles  of  the  machine.  The  best  results  should  be  ob- 
tained when  the  spark  gap  is  run  up  to  three  or  our 
to  six  inches.  Each  spark  means  a  surging  of  electric- 
ity through  the  patient  with  the  greatest  force  applied 
in  the  tissues  immediately  under  the  electrode.  This 
produces  a  contraction  of  the  tissues.  Thus  with  each 
blow  there  is  a  squeezing  out  of  any  infiltration  into 
the  proper  channels  for  elimination.  In  this  way  de- 
pletion is  accomplished.  Another  effect  is  of  the  elec- 
tricity itself  by  way  of  stimulation  to  the  nerve  supply 
and  circulation,  thus  tending  in  a  very  positive  way  to 
assist  nature  by  her  own  processes  to  restore  locally 
the  "  normal."  Following  the  wave  current,  a  short 
seance  of  direct  sparking,  pressing  spark  selector  hard 
against  the  boggy  area  and  with  the  sparking  ball  giv- 
ing spark  of  one-half  or  three-quarters  to  one  inch  in 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         \?j 

length  in  order  to  insure  its  penetration  into  the  villous 
growth  beneath.  In  a  tender  and  aching  joint  these 
treatments  may  be  followed  by  the  so-called  brush  dis- 
charge. The  patient  is  seated  on  the  insulated  table 
and  connected,  by  the  shepherd's  crook  with  the  nega- 
tive pole  of  the  static  machine.  Then  the  operator 
with  the  metallic  rod  or  the  "  wet  stick  "  connected  by 
a  special  chain  with  the  earth,  draws  the  electricity 
from  the  patient  at  the  point  of  greatest  tenderness. 
This  modality  is  a  great  sedative  and  is  very  soothing 
to  such  joints.  Another  method  of  treatment,  but  not 
advocated  as  much  as  formerly  is  the  actual  cautery. 
It  is  of  value  and  now  and  then  seems  to  be  the  one 
treatment  needed  for  cure.  But  to  use  for  regular 
treatment,  it  will  prove  disappointing.  A  simple  treat- 
ment which  can  be  made  use  of  at  home  is  hot  and  cold 
douching.  Alternately  pouring  hot  and  cold  water 
over  the  knee  produces  a  succession  of  mild  shocks  and 
a  mild  hypersemia  which  will  be  of  benefit  in  a  few 
cases. 

Another  simple  method  is  to  bandage  the  joint  with 
a  pure  (gum)  rubber  bandage.  This  produces  a  local 
sweating  and  thus  is  beneficial.  In  some  few  of  these 
knees,  the  boggy  condition  may  yield,  and  yet  there 
may  remain  a  tender  area  way  beneath  the  ligamen- 
tum  patellae,  and  usually  on  the  inner  side.  At  this 
point  of  tenderness,  a  small  tumor  may  be  felt  to  roll 
under  the  finger.  This  is  a  villus  which  may  be  fibrous 


14  THE    CLASSIFICATION    AND    TREATMENT    OF 

and  hard,  or  it  may  have  undergone  fatty  degenera- 
tion. In  either  case,  surgical  removal  brings  an  end 
to  all  trouble  from  that  source. 

There  are  now  two  types  of  joint  troubles  which 
have  been  classified  as  the  trophic  types.  That  is, 
atrophic  and  hypertrophic  arthritis.  With  the  other 
types  to  be  described,  they  are  all  due  to  faulty  metab- 
olism ;  that  is,  there  is  somewhere  in  the  system  faulty 
physiology.  It  is  often  impossible  to  locate  the  exact 
process  at  fault,  but  it  has  been  demonstrated  very 
many  times  that  treatment  applied  in  such  a  manner 
as  to  stimulate  the  physiological  processes  to  act  in  a 
normal  or  more  nearly  normal  manner,  slowly  results 
in  an  improvement  in  the  joint  conditions.  One  type 
is  usually  first  observed  in  the  smaller  joints  (fingers), 
later  involving  the  larger  joints  (knees).  The  cervi- 
cal vertebrae  (joints)  may  be  involved  but  usually  for  a 
short  interval  only,  when  it  clears  up,  very  seldom  in- 
deed resulting  in  a  completely  stiffened  neck.  The 
jaws  are  also  involved  sometimes  (not  usually).  The 
synovial  membrane  becomes  thickened  and  spongy  and 
full  of  blood,  thus  giving  the  joint  a  swollen  and  boggy 
appearance.  If  the  knee  is  involved  instead  of  getting 
the  sense  of  fluctuation  when  the  patella  is  depressed, 
it  gives  the  sensation  of  striking  on  rubber,  there  being 
an  entire  absence  of  the  sharp  click  which  is  such  a 
familiar  sound  and  so  easily  sensed  in  a  simple  synovi- 
tis.    Later    the   cartilage  is  involved,   resulting  in  a 


DISEASES    COMMONLY    KKOWN    AS    RHEUMATISM.         15 

thinning  or  atrophy.  If  the  cartilage  becomes  more 
and  more  thinned,  there  appears  small  a,reas  of  com- 
plete erosion,  these  growing  slowly  larger  and  when 
the  areas  are  on  opposite  bones  and  near  each  other, 
bony  anchylosis  may  ultimately  result.  When  the 
thinning  or  atrophy  takes  place  in  the  finger  joints,  the 
cartilage  may  become  destroyed  and  the  ends  of  the 
bones  being  forced  together  spread  out  laterally,  thus 
making  the  joint  enlarged.  This  is  the  type  of  finger 
joint  where  this  enlargement  was  formerly  supposed 
to  be  a  deposit,  but  now  the  X-ray  shows  the  exact 
condition.  These  enlarged  finger  joints  were  also  very 
apt  formerly  to  be  called  gout,  or  worse  yet  rheumatic 
gout.  The  enlargement  is  thus  due  to  the  thickened 
synovia  and  villi,  and  some  infiltration  of  soft  parts 
and  to  the  projecting  bony  contours,  and  is  not  a  de- 
posit at  all.  As  the  principal  thing  in  this  type  of 
trouble  is  the  thinning  or  atrophy  of  the  cartilage,  it 
has  been  classified  as  atrophic  arthritis. 

In  the  knee  joints,  the  villi  become  of  considerable 
size  and  then  undergo  fatty  degeneration  or  else  the 
ends  may  become  calcified.  These  calcified  tips  may 
break  off  from  the  pedicles  and  thus  become  floating 
cartileges.  There  may  be  only  two  or  three  villi  of 
some  size  under  the  ligamentum  patellae,  usually  on  the 
inner  side.  In  this  position,  they  become  pinched  in 
walking  and  getting  tender  give  trouble  both  on  ac- 
count of  the  tenderness  and  pain  and  on  account  of  the 


16  THE   CLASSIFICATION    AND    TREATMENT    OF 

mechanical  interference  with  the  mechanism  of  the 
joint.  This  Jype  of  joint  trouble  is  very  slow  (chronic) 
but  continuously  progressive.  It  requires  several  years 
to  run  through  its  course  and  also  may  remain  slowly 
advancing  throughout  life.  The  enlarged  terminal 
joints  of  the  fingers  are  usually  the  first  symptoms  and 
during  the  active  stage  of  atrophy  and  projecting  bony 
contours,  may  become  painful.  Later  when  the  larger 
joints  (knees)  are  involved,  there  is  more  pain  on  ac- 
count of  the  villous  arthritis  as  well  as  the  eroded  sur- 
faces and  it  is  not  uncommon  to  have  the  flexor  mus- 
cles of  such  joints  contract,  these  muscular  contractures 
becoming  of  importance  in  treatment.  In  this  class  of 
cases  some  patients  may  go  along  with  slowly  enlarg- 
ing finger  joints  and  involvement  of  larger  joints  re- 
sulting in  more  or  less  of  an  anchylosis.  Over  these 
joints  some  of  the  enlargement  is  very  evidently  due 
to  an  infiltration  of  the  soft  structures.  In  some  other 
cases,  if  observed  from  time  to  time,  these  finger  joints 
mav  become  more  or  less  tender  and  even  now  and 
then  somewhat  red  and  inflamed  (low  grade).  Usually 
these  joints  do  not  give  so  very  much  pain  but  are 
achy  and  tender  (if  knees)  when  walking  or  weight 
bearing.  They  are  stiff  and  the  knees  bother  much  in 
going  up  or  down  stairs,  the  villi  and  erosions  causing 
grating  and  creaking.  It  is  necessary  to  consider  the 
causes  of  this  trouble  as  the  modern  treatment  is 
aimed  very  largely  at   such    causes.     It   is   becoming 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         17 

more  and  more  evident,  as  the  result  of  treatment  is 
observed,  that  this  type  of  joint  trouble  is  due  to  faulty 
physiology  somewhere  and  that  if  it  can  be  stimulated 
to  do  its  work  properly,  the  joints  slowly  get  well. 

It  goes  without  saying  that  when  cartilage  has  been 
destroyed,  it  cannot  be  restored.  To  stimulate  the 
physiology,  various  means  are  employed  but  first  of  all 
it  may  as  well  be  said  that  medicine  (drugs)  simply 
will  not  do  it._  Persons  who  are  under  a  great  deal  of 
tension  either  from  worry,  grief,  etc.,  (mental  tension) 
or  overwork  (physical  tension)  or  both  which  is  still 
worse,  may  slowly  develop  this  trouble,  but  it  is  caused 
by  the  interference  with  physiology.  Patients  who 
have  already  had  this  type  of  trouble,  even  for  years, 
may  be  made  worse  by  grief  and  sorrow  and  with  the 
passing  of  such  trouble  may  improve  and  get  back  to 
their  former  stage  of  the  process  just  as  before.  Sor- 
row or  mental  strain  interferes  mostly  in  the  way  of 
digestion.  Any  one  who  has  had  a  severe  worry  for  a 
short  time  knows  of  what  little  use  it  is  to  eat,  as  the 
food  remains  in  the  stomach  for  a  long  time  as  a  "  lump 
of  distress  "  before  it  passes  on  and  even  may  continue 
to  give  intestinal  disturbance  all  the  way  through. 
Such  people  may  become  constipated  or  even  diarrhea 
may  be  produced.  In  this  way,  assimilation  is  inter- 
fered with  or  the  lymphatic  stream  is  not  properly  pre- 
pared. This  would  cover  only  a  very  small  number 
of  the  cases,  however,  most  of  them  beginning  in  a 


18  THE    CLASSIFICATION    AND    TREATMENT    OF 

very  insidious  manner,  the  patient  probably  not  notic- 
ing it  for  a  long  time.  A  careful  history  is  a  great 
help,  followed  by  a  thorough  physical  examination 
and  an  X-ray  photograph  of  one  or  more  of  the  joints, 
to  make  sure  of  this  type.  The  patient  may  be  doing 
entirely  too  much  (physical  strain)  or  (usually)  it  will 
be  found  that  there  is  something  wrong  in  the  alimen- 
tary canal  somewhere,  irregular  eating,  too  rapid  eat- 
ing, faulty  preparation  of  food  in  the  mouth  from  bad 
teeth  or  insufficient  teeth.  The  stomach  or  intestines 
may  be  interfered  with  in  their  working  by  corsets  and 
clothing.  The  liver  may  be  doing  its  work  poorly  and 
thus  be  a  disturbing  factor. 

Perhaps  the  most  typical  case  simply  comes  on 
slowly,  usually  the  finger  joints  followed  by  larger 
joints,  or  the  fingers  may  never  become  involved  and 
only  the  knees  and  hips  be  attacked.  In  such  a  case 
there  would  not  be  much  pain  but  the  symptom  most 
complained  of  would  be  stiffness.  After  sitting  for  an 
hour,  the  joints  would  be  very  stiff  on  first  getting  up. 
While  sitting  or  lying  down,  there  would  be  an  entire 
absence  of  discomfort.  Consequently  sleep  is  not  in- 
terfered with.  On  getting  up  and  attempting  to  go  up 
or  down  stairs,  there  is  a  stiffness  and  later  a  limita- 
tion in  motion.  Now  this  limitation  in  motion  in  such 
a  case  where  there  is  no  villous  arthritis  and  no  ero- 
sion, is  due  to  a  beginning  fibrosis.  In  such  a  case, 
the    faulty    physiology  must    result  in    absorption  of 


DISEASES    COMMONLY-    KNOWN    AS    RHEUMATISM.         19 

products  which  result  in  this  condition  without  causing 
any  temperature.  Such  joints,  if  manipulated  under 
ether  appear  perfectly  freely  movable  without  any  ap- 
parent grating  and  roughening.  In  other  words  they 
feel  like  perfectly  normal  joints.  This  resistance  in  the 
earliest  stages  would  seem  to  be  located  in  the  liga- 
ments. Such  manipulations  however  are  to  be  avoided 
as  the  result  is  to  produce  a  marked  stiffening  and  pain 
on  voluntary  motion.  This  aggravated  condition  may 
last  for  weeks  and  months  before  getting  back  to  the 
former  state,  thus  causing  the  patient  just  so  much  un- 
necessary pain  and  discomfort.  That  this  trouble  is 
due  to  absorption  or  faulty  assimilation  is  brought  out 
by  the  fact  that  a  case  that  has  gone  along  for  months 
and  even  years  in  this  way  with  a  slowly  increasing 
fibrosis,  may  begin  to  have  the  first  mild  attacks  of 
swollen  joints  especially  in  the  fingers.  As  time  goes 
on  and  this  phase  of  the  disease  appears,  these  at- 
tacks may  gradually  become  more  severe  and  a  tem- 
perature exists  in  proportion  to  the  amount  of  inflam- 
mation. In  such  a  case,  the  patient  must  be  carefully 
questioned.  The  method  of  eating  is  highly  import- 
ant. In  the  first  place  not  too  much  must  be  placed 
in  the  mouth  at  any  one  time.  This  gives  a  chance  to 
chew  and  mix  it  thoroughly  with  saliva.  It  will  be 
found  that  most  people  put  the  food  into  the  mouth  in 
rather  too  large  quantities,  chew  a  little  and  then 
either  swallow  it  by  pushing  it  down,  by  taking  a  drink 


20  THE    CLASSIFICATION   AND    TREATMENT    OF 

of  water,  coffee,  tea,  or  whatever  the  favorite  drink 
may  be.  Eating  in  this  way,  there  is  not  much  de- 
mand made  on  the  salivary  glands  and  in  consequence 
they  "  get  out  of  practice  "  as  it  were  ;  and  as  a  chronic 
thing  not  much  saliva  is  secreted.  This  is  the  first 
step  in  digestion  and  it  is  right  here  that  faulty  physi- 
ology begins  and  must  be  corrected.  This  is  a  highly 
important  part  of  the  treatment  and  patients  must 
have  it  explained  to  them  in  detail,  so  that  they  may 
appreciate  the  situation.  When  the  food  is  chewed  and 
thoroughly  mixed  with  saliva,  swallowing  practically 
becomes  an  automatic  process  and  the  food  swallows 
itself.  Towards  the  end  of  the  meal,  one  becomes  con- 
scious of  forcing  the  muscles  to  swallow.  Then  appe- 
tite has  been  appeased  and  the  meal  must  be  consid- 
ered completed  right  there.  If  this  method  of  eating 
is  pursued,  the  salivary  glands  secrete  the  juice  much 
faster  and  if  drinking  for  the  purpose  of  washing  down 
the  food  is  done  away  with,  the  desire  for  drink  while 
eating  disappears.  Eating  in  this  way  after  it  has 
been  practised  so  that  one  does  it  unconsciously  does 
not  require  much,  if  any  more,  time  than  the  old  way. 
It  will  be  seen  that  water  is  thus  done  away  with  quite 
naturally  at  meal  time,  and  so  must  be  taken  care  of 
between  meals.  In  the  morning  before  breakfast  is  a 
good  time  to  drink  as  the  water  is  absorbed  very 
quickly  in  the  stomach  that  has  been  empty  several 
hours,    then    middle    forenoon,  middle  afternoon  and 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         21 

evening.  If  water  is  not  drunk  constipation  results 
with  a  still  greater  auto-intoxication.  Food  prepared 
in  this  way  enters  the  stomach  ready  for  its  treatment 
with  gastric  juice  then  to  be  sent  on  into  the  intestines. 
In  men  the  abdominal  contents  are  not  displaced  by 
corsets,  but  in  women  this  is  an  extremely  important 
factor  in  digestion.  The  conventional  corset  constricts 
at  the  waist  line  (the  small  waist  is  a  fashionable  neces- 
sity) thus  forcing  the  contents  downwards.  Even  the 
long  corsets  do  not  support  from  below  as  they  ought 
to.  This  constriction  and  forcing  downwards  of  the 
abdominal  contents  interferes  with  intestinal  action 
and  thus  the  physiological  activity,  whereby  the  intes- 
tinal juices  are  secreted,  is  interfered  with.  This  sag- 
ging of  the  intestines  and  diminished  intestinal  secre- 
tions mean  a  slowing  of  the  intestinal  stream  with  its 
consequent  constipation  and  the  formation  of  bacteria 
and  toxines.  Also  the  end  products  which  are  finally 
supplied  to  end  organs  are  changed  as  to  their  compo- 
sition. In  this  way,  nutrition  is  interfered  with.  The 
whole  physiology  is  demoralized,  any  way  in  portions 
of  it,  which  seems  to  result  in  trophic  joint  troubles. 
The  liver  also  is  an  extremely  important  organ  in  all 
these  troubles.  It  stands  between  the  alimentary  ca- 
nal and  the  final  stream  which  distributes  to  the  vari- 
ous physiological  depots  and  serves  to  filter  out  the 
infections  and  toxines.  When  it  is  not  acting  properly 
and  some  of  these  products  are  allowed  to  pass  through, 
then  some  of  these  various  joint  disturbances  arise. 


22  THE    CLASSIFICATION    AND    TREATMENT    OF 

The  proper  preparation  of  the  food  in  the  mouth 
having  been  described,  the  treatment  of  faulty  diges- 
tion in  the  stomach  and  intestine  must  be  corrected 
likewise.  A  liver  which  is  not  doing  its  work  properly 
must  be  attended  to.  Each  pair  of  conventional  cor- 
sets which  }^ou  may  examine  "  in  situ "  will  show  a 
waist  line  more  or  less  constricted  and  from  this  waist 
line  downward  the  corset  is  so  made  that  it  does  not 
support  the  abdominal  organs.  This  constant  pressure 
and  the  downward  sagging,  causes  atony  and  weak- 
ening of  all  the  muscular  walls,  hence  a  marked  slow- 
ing of  the  physiological  digestive  process.  As  a  result 
there  is  a  backing  up  of  the  partially  digested  products 
with  a  resulting  putrefaction  and  growth  of  the  various 
bacteria  and  their  toxines.  These  are  carried  through 
the  system  and  as  a  result  among  other  things,  the 
joints  are  affected.  These  are  the  true  causative  fac- 
tors and  must  be  remedied.  The  corset  must  be  taken 
in  hand,  and  an  extension  made  and  fitted  in  such  a 
manner  that  the  lower  end  passes  beneath  the  abdomen, 
and,  by  being  perfectly  fitted  and  moulded,  really  sup- 
port the  abdominal  contents.  Then  the  corset  must 
be  laced  in  three  sections,  the  lower  one  sufficiently 
tight  so  that  proper  support  and  pressure  upward  is 
really  obtained.  The  section  at  the  waist  line  must  be 
looser  so  that  the  organs  will  have  space  for  them  to 
go  when  they  are  pushed  upward  and  the  upper  sec- 
tion should  be  loosest  of  all  to  allow  perfect  freedom 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         23 

for  breathing.  The  corset  makers  are  apparently 
unable  to  do  this  and  so  the  physician  must  do  this 
work  in  order  to  be  sure  that  it  is  anatomically  correct. 
In  this  way  support  of  the  abdominal  contents  is 
obtained  and  a  shortening  of  the  supporting  ligaments 
and  structures.  The  next  thing  in  treatment  is  to 
stimulate  in  some  way  the  functions  of  these  organs, 
to  restore  tone  to  the  muscular  fibres  which  "  work  " 
the  stomach  and  the  intestines,  and  to  tone  up  also  the 
supporting  structures  so  that  sagging  will  not  be  so 
marked.  This  is  done  most  effectively  by  some  of  the 
forms  of  electricity  and  mechano-therapy  (vibration). 
General  vibration  will  very  markedly  stimulate  phy- 
siological processes.  In  the  first  place  a  vibrator  with 
a  massive  base  is  a  necessity,  if  the  vibration  is  really 
to  be  "  sent  in "  and  to  produce  the  desired  results. 
"Why  so  many  fail  to  produce  these  results  is  that  they 
buy  a  small  and  light  vibrator  where  a  large  part  of 
the  vibration  wave  is  taken  up  by  the  hands  of  the 
operator  and  hence  not  transmitted  through  the  tissues 
except  in  a  very  insufficient  way.  The  hard  ball  of 
the  vibrator  is  used  on  the  nerve  centres  between  the 
transverse  processes  up  and  down  the  spine.  In  this 
way,  waves  of  energy  are  transmitted  along  the  nerves 
to  the  various  organs  and  structures  at  the  end  of  the 
nerves.  A  pressure  of  from  five  to  eight  or  ten 
seconds  is  stimulating.  A  longer  pressure  would  be 
inhibitory.     The  soft  brush  is  now  used  over  the  liver 


24  THE    CLASSIFICATION    AND   TREATMENT    OF 

both  front  and  back.  This  organ  can  be  very  markedly 
stimulated  by  this  means  and  in  a  way  which  cannot 
even  be  approximated  by  medicine.  The  soft  brush 
of  the  vibrator  is  continued  over  the  stomach  area,  the 
hard  ball  over  the  abdominal  lymphatics  and  again  the 
soft  brush  over  the  general  area  of  the  abdomen. 
These  latter  measures  stimulate  the  stomach  as  an 
individual  organ  increasing  the  tone  of  its  muscles, 
thereby  increasing  its  efficiency  in  work  accomplished. 
Likewise  the  muscles  in  the  walls  of  the  intestines  are 
markedly  stimulated  also  increasing  their  efficiency 
and  the  abdominal  lymphatics  are  likewise  stimulated 
to  do  better  work.  All  this  means  increasingly  better 
preparation  of  food  for  assimilation.  The  stimulation 
applied  thus  directly  to  the  muscular  walls  raises  the 
tone  of  these  organs  and  thus  largely  corrects  the  sag- 
ging of  the  abdominal  viscera.  In  this  improved  con- 
dition, the  intestines  perform  their  functions  better 
and  better  and  the  assimilation  of  food  (end)  products 
is  accomplished  in  a  more  nearly  normal  physiological 
manner.  With  the  improved  tone  in  the  muscular 
walls  of  the  abdominal  viscera,  there  is  less  and  less 
backing  up  of  the  stream  and  hence  less  and  less  de- 
composition which  means  less  and  less  absorption  of 
bacteria  and  toxines.  If  this  absorption  of  bacteria 
and  toxines  is  the  real  cause  of  chronic  joint  disease, 
it  is  at  once  seen  that  these  conditions  are  in  this  way 
attacked  right  at  the  source  of  all  trouble.     With  this 


DISEASES    COMMONLY    KNOWN   AS    RHEUMATISM.        25 

correction  of  the  physiological  process,  the  bacteria  or 
toxines  cease  to  be  sent  into  circulation  for  distribution 
and  thus  the  onward  progress  of  the  disease  becomes 
slowly  checked.  At  the  same  time  this  general  treat- 
ment is  given,  aimed  at  the  direct  cause  of  the  trouble, 
the  joints  themselves  must  receive  careful  attention. 
Vibration  may  be  used  to  stimulate  the  tissues  and 
their  local  processes.  The  soft  brush  may  be  used  on 
the  wrist  and  finger  joints  making  a  pretty  firm  pres- 
sure on  both  palmer  and  dorsal  surfaces.  The  soft 
brush  may  also  be  used  on  the  elbow,  shoulders,  hips 
or  ankle  joints.  On  the  knees  much  better  work  may 
be  done  by  the  hard  ball.  If  a  villous  arthritis  is  pres- 
ent, as  it  is  so  apt  to  be,  the  hard  ball  is  a  very  efficient 
means  of  causing  a  contraction  and  slow  disappearance 
of  the  condition.  In  addition  to  the  mechanical  vibra- 
tion as  above  described,  some  of  the  newer  electrical 
modalities  are  of  very  great  service  in  producing  cer- 
tain very  definite  results.  The  wave  current  is  a  very 
strong  tonic  to  the  general  system.  This  may  be 
applied  by  a  long  flexible  metal  electrode  placed  long- 
itudinally along  the  spine  and  connected  to  the  positive 
pole  of  the  static  machine,  the  patient  being  seated 
upon  an  insulated  table.  The  negative  pole  of  the 
machine  is  grounded  by  a  chain  leading  to  a  special 
steel  rod  driven  into  the  earth  and  the  dosage  is  reg- 
ulated by  the  length  of  spark  gap  between  the  poles 
of  the  machine.     The  longer  the  spark  gap,  the  deeper 


26  THE   CLASSIFICATION    AND    TREATMENT    OF 

the  impulse  of  the  "  wave  "  penetrates  into  the  tissues. 
If  the  metallic  electrode  is  placed  over  one  of  the  dis- 
eased joints,  it  derives  more  benefit  because  the 
greatest  effect  on  tissue  is  obtained  directly  under  the 
metallic  electrode.  In  case  of  knees,  if  a  large  machine 
is  employed,  a  metallic  electrode  may  be  applied  to 
each  knee  and  both  connected  to  the  positive  pole  thus 
getting  the  maximum  effect  directly  upon  the  knees. 
This  treatment  is  allowed  to  continue  usually  for 
twenty  minutes.  Following  this,  the  affected  joints 
may  be  given  a  thorough  sparking.  It  is  better  to  use 
the  spark  selector  (Snow)  by  which  it  is  possible  to 
deliver  the  spark  just  where  it  is  needed.  The  patient 
is  seated  on  the  insulated  table  and  connected  by  the 
shepherd's  crook  with  the  positive  pole  of  the  machine. 
The  negative  side  of  the  machine  is  grounded  by  a 
special  steel  rod.  The  operator  with  spark  selector 
and  ball  (the  ball  being  grounded  by  a  chain  connected 
with  gas  or  water  pipe)  thoroughly  sparks  the  tissues 
all  around  the  knees  with  a  length  of  spark  which 
should  penetrate  one-half  or  three-quarters  of  an  inch. 
Neither  of  these  treatments  are  painful  to  the  patient 
as  the  metallic  electrodes  are  in  close  contact  with  the 
skin  when  the  wave  current  is  given  and  the  spark 
selector  is  in  actual  contact  with  the  skin  as  each  spark 
is  delivered,  hence  it  is  sent  in  without  discomfort  to 
the  patient.  With  the  wave  current,  as  each  spark 
jumps  across  the  poles  of  the  machine,  a  current  of 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         27 

electricity  surges  through  the  body  with  the  maximum 
effect  at  the  joint.  A  contraction  of  tissues  takes  place 
thus  squeezing  out  any  infiltration  which  may  exist 
and  has  a  marked  contractile  effect  upon  the  spongy 
tissue  like  a  villous  arthritis.  The  spark  sent  in  by 
the  spark  selector  has  the  same  effect  only  it  is  local- 
ized more  exactly  in  this  way. 

If  the  joint  is  particularly  tender  or  painful,  the 
wave  current  and  sparking  may  be  followed  by  the 
brush  discharge.  This  may  be  obtained  by  the  metal- 
lic (pointed)  electrode  or  the  wet  stick  electrode.  The 
patient  is  seated  upon  the  insulated  table  connected  to 
the  negative  side  of  the  machine  by  the  shepherd's 
crook,  while  the  positive  pole  is  grounded.  The  me- 
tallic pointed  electrode  or  the  wet  stick  is  connected 
with  the  earth  by  means  of  a  chain  to  the  water  pipe 
or  gas  pipe.  The  point  of  either  electrode  is  then  held 
within  one  or  two  inches  according  to  the  effect  pro- 
duced and  if  the  room  be  darkened,  a  fine  purple  or 
violet  spray  may  be  seen  between  the  skin  and  the 
electrode.  This  relieves  pain  and  tenderness  in  many 
cases.  Another  treatment  which  strongly  stimulates 
the  nerve  centres,  is  to  have  the  patient  reclining  upon 
a  couch,  the  back  bared  to  the  skin  and  then  exposed 
up  and  down  its  whole  length  to  the  light  emanating 
from  a  five  hundred  candle  power  incandescent  lamp. 
The  stimulation  of  these  nerve  centres  conve}^  im- 
pulses to  the  various  end  organs  corresponding  to  these 


28  THE    CLASSIFICATION    AND    TREATMENT    OF 

centres  and  thus  the  physiolog}7  of  the  abdominal  or- 
gans is  reached.  If  one  joint  is  especially  painful  or 
achy,  a  twenty  minute  exposure  to  this  light  will  often 
serve  to  completely  alleviate  the  pain.  The  enlarge- 
ment (infiltration  of  soft  structures)  of  the  small  joints 
(fingers)  is  stimulated  usually  in  a  very  noticeable 
manner  by  the  D' Arson val  current.  These  joints  may 
be  made  to  contract  and  diminish  in  size  in  this  way 
sometimes  when  other  methods  fail.  A  small  metal 
electrode  is  bandaged  to  the  palmer  surface  of  the  fin- 
gers and  the  D' Arson  val  current  applied  by  placing 
the  glass  vacuum  electrode  over  the  dorsal  surface. 
This  treatment  may  be  continued  for  ten  minutes  on 
each  hand.  In  an  atrophic  type  with  marked  villous 
arthritis  of  the  knees  which  might  resist  all  treatment, 
opening  the  joint  and  thoroughly  cleaning  out  the  vil- 
lous growth  with  forceps  and  scissors  will  put  an  end 
to  the  trouble  in  that  particular  joint.  After  the  oper- 
ation splints  are  used  and  walking  is  allowed  at  the 
end  of  a  week  or  ten  days.  Another  clinical  picture 
of  joint  trouble  is  the  hypertrophic  type.  In  order  that 
the  treatment  may  be  shown  as  logical  and  rational, 
the  condition  of  the  joints  will  have  to  be  shown  a  lit- 
tle in  detail  and  the  etiology  discussed.  The  principal 
characteristic  of  this  condition  is  the  overgrowth  of 
bone  or  cartilage  usually  at  the  edges  of  the  articular 
surfaces.  The  stage  of  actual  hypertrophy  is  a  late 
stage  as  may  be  quite  definitely  proved  by  considering 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         29 

the  process  when  it  attacks  the  spine  where  it  is  most 
often  spoken  of  as  an  osteoarthritis.  In  this  location 
the  patient  consults  a  physician  at  a  much  earlier  stage 
than  when  some  of  the  areas  of  joints  are  involved. 
In  this  stage  there  is  pain  on  motion  of  the  spine  in 
flexing  and  side  bending  which  interferes  very  directly 
with  occupation  and  from  the  fact  that  the  spine  is  in- 
volved, patients  are  earlier  referred  to  the  orthopedic 
physician  and  not  so  much  time  is  wasted  while  the 
condition  is  treated  with  the  usual  anti-rheumatic  rem- 
edies. In  the  earliest  stage  hardly  any  hypertrophy 
or  overgrowth  of  bone  exists,  but  there  is  an  infiltra- 
tion of  the  soft  structures  which  is  undoubtedly  due  to 
auto-infection  (either  toxines  or  bacteria). 

This  thickening  is  usually  confined  to  one  side  only  in 
the  beginning,  and  so  when  the  patient  stands  with  back 
towards  the  observer,  lateral  bending  shows  the  spine 
curved  normally  to  one  side  and  limited  in  its  excur- 
sion on  the  other.  When  both  sides  are  involved  the 
excursion  on  both  sides  is  limited  and  usually  one  side 
more  than  the  other.  Slowly  as  time  goes  by,  there 
takes  place  a  deposit  of  bone  salts  and  if  not  arrested 
the  vertebrae  become  fused  together  in  a  condition  of 
anchylosis.  In  this  stage  which  precedes  actual  bone 
formation  the  condition  is  ordinarily  completely  cura- 
ble. The  wave  current  may  be  applied  with  long  me- 
tallic electrode,  twelve  to  fourteen  inches  long,  by 
three  inches  wide,  placed  directly  over  the  affected  re- 


30  THE   CLASSIFICATION    AND    TREATMENT    OF 

gion  and  being  connected  with  the  positive  pole  of  the 
machine  as  described  above,  continue  the  treatment 
for  twenty  minutes  with  a  spark  gap  of  four  to  six 
inches.  This  should  be  followed  by  sparking  as  de- 
scribed above  with  the  spark  selector,  pressing  the  end 
deeply  into  the  intervertebral  spaces  all  up  and  down 
the  affected  area.  This  treatment  causes  the  contrac- 
tion of  the  tissues  which  squeezes  out  and  depletes, 
also  stimulating  activity  in  the  nerve  supply  and  cir- 
culation thus  markedly  hastening  local  elimination. 
This  may  be  followed  by  a  general  vibration,  the  hard 
ball  in  the  intervertebral  spaces,  stimulating  the  nerve 
centres  which  convey  impulses  to  end  organs  (abdomi- 
nal viscera)  and  the  soft  brush  over  the  liver,  both 
front  and  back,  and  also  generally  over  the  abdominal 
area.  Also  the  hard  ball  is  used  over  the  abdominal 
lymphatics.  In  this  way  the  abdominal  organs  are 
stimulated  to  perform  their  functions  in  a  more  nearly 
normal  physiological  manner  and  as  the  normal  is  ap- 
proached, the  backing  up  of  the  stream  with  its  conse- 
quent constipation,  formation  of  ferments,  bacteria  and 
toxines  are  slowly  caused  to  disappear.  Many  of  these 
patients  have  more  than  an  unnoticed  sluggishness  in 
liver  and  intestines.  They  may  actively  complain  of 
symptoms  of  indigestion,  either  stomach  or  intestines, 
and  it  is  very  common  to  find,  when  using  the  vibra- 
tor, that  there  are  tender  spots  over  the  spine  which 
correspond  accurately  (as  now  mapped  out  in  the  phys- 


DISEASES    COMMONLY   KNOWN    AS    RHEUMATISM.         31 

iology)  to  the  centres  for  the  liver  as  well  as  other  ab- 
dominal viscera  and  it  is  not  uncommon  to  find  the 
whole  liver  area  somewhat  tender  on  precussion. 

An  extremely  marked  case  came  under  observation 
this  last  winter.  A  woman  of  forty  or  forty-five  was 
referred  to  the  writer  because  of  a  very  tender  and  sen- 
sitive spine.  It  was  considered  as  some  spinal  disease 
because  of  the  location  in  the  spine,  the  patient  being 
confined  to  bed,  because  supporting  the  superincum- 
bent body  weight  caused  pain  in  the  tender  area  of  the 
spine.  Turning  in  bed  was  also  uncomfortable.  Phys- 
ical examination  revealed  three  or  four  vertebrse  very 
tender.  Very  slight  pressure  caused  pain  and  flinch- 
ing. As  this  area  corresponded  accurately  with  the 
nerve  centres  for  the  liver,  an  examination  both  front 
and  back  showed  that  this  whole  surface  area  directly 
over  the  liver  was  extremely  sensitive  to  pressure. 
Thus  a  complete  clinical  picture  showing  that  conges- 
ted liver,  by  its  reflex  effect  on  the  nerve  centres  had 
produced  so  tender  a  spine  that  some  disease  of  the 
spine  had  been  diagnosed.  The  proof  of  the  diagnosis 
seemed  to  be  confirmed  by  the  fact  that  when  the  liver 
was  depleted  by  appropriate  treatment,  the  spine  gave 
no  evidence  of  disease  and  tenderness,  and  the  patient 
has  remained  well  several  months  now  since  the  at- 
tack. Thus  in  the  early  stage  of  osteo-arthritis  often 
called  rheumatism  of  the  spine,  in  this  location  it  would 
seem  that  the  direct  results  of  treatment  had  been  such 


32  THE    CLASSIFICATION    AND    TREATMENT    OF 

as  to  prove  very  conclusive]}^  the  localized  infiltration 
(auto-infection)  and  that  this  condition  is  usually  cura- 
ble any  way  in  the  stages  preceding  the  actual  deposit 
of  bone  salts.  If  the  infiltration  continues  there  may 
be  severe  pressure  of  the  nerve  trunks  even  without 
bone  formation.  This  pressure  usually  results  in  pain 
in  the  nerve  terminals  as  well  as  discomfort  and  ten- 
derness at  the  point  of  infiltration.  This  may  be  so 
severe  that  patients  are  no  longer  able  to  continue  at 
their  work  or  occupation.  Under  such  conditions, 
quick  relief  may  be  obtained  by  the  application  of  a 
plaster  jacket  with  the  spine  held  in  a  somewhat  hy- 
per-extended position  on  a  frame,  or  if  too  tender  for 
that,  the  first  jacket  may  be  applied  with  the  patient 
standing  in  the  best  position  he  can  assume,  and  after 
the  relief  thus  afforded,  a  second  jacket  could  be  ap- 
plied a  week  or  two  later  when  the  spine  could  be 
made  perfectly  straight  or  even  hyper-extended.  The 
first  or  second  jacket  could  be  a  removable  one  in  or- 
der that  the  treatments  as  outlined  above  might  be  in- 
stituted and  a  complete  cure  obtained.  The  relief  un- 
der these  conditions  is  somewhat  startling  in  its  sud- 
denness. A  case  in  point  may  be  briefly  mentioned. 
A  man  of  about  forty  years,  whose  business  called 
upon  him  to  be  on  his  feet  a  great  part  of  the  day,  run- 
ning in  and  out,  and  up  and  down  stairs,  was  attacked 
with  this  condition  in  the  spine.  Pressure  on  the 
nerve  trunks  had  taken  place  and  the  pain  developed 


DISEASES    COMMONLY    KNOWN    AS    KHEUMATISM.         33 

at  the  terminal  nerve  areas  around  the  inner  side  of 
the  knee  and  about  the  ankle  joint.  He  had  been  ex- 
amined and  prescribed  for  by  half  a  dozen  medical 
men  who  had  all  examined  his  knee  and  ankle  and  con- 
sidered it  neuralgia  and  neuritis  of  these  joints.  The 
patient  was  in  bed  at  my  first  visit.  The  next  day  a 
plaster  jacket  was  applied  in  the  standing  position  and 
two  days  later  when  I  made  my  visit,  the  patient  had 
gone  down  town.  A  few  days  later  he  reported  at  my 
office.     He  was  back  at  work  and  free  from  pain. 

In  the  later  stages  after  bone  salts  are  deposited  and 
pressure  has  taken  place  with  its  consequent  pain  in 
the  nerve  terminals  usually  somewhere  down  the  leg, 
the  jackets  as  just  described  are  necessary,  and  if  the 
process  has  gone  on  far  enough  and  the  spine  is  bent 
over  forwards,  some  of  the  curve  and  in  some  cases  all 
of  it  may  be  corrected  by  successive  jackets,  with  or 
without  ether.  At  the  same  time  that  pressure  is 
removed,  pain  is  relieved  and  the  patient  really  lives 
again.  After  the  spine  is  straight,  the  jacket  is  made 
removable  or  a  lace-up  leather  jacket  is  applied  so  that 
the  treatment  of  the  spine  and  of  general  physiology 
may  be  administered.  In  such  cases,  where  bone  salts 
have  been  deposited  there  can  be  no  absorption,  but 
the  process  may  be  halted  so  that  no  more  will  be 
deposited  and  the  physiology,  as  described  above  got- 
ten in  a  normal  or  more  nearly  normal  condition. 
Under  these   conditions,    there   is   undoubtedly   some 


34  THE    CLASSIFICATION    AND    TREATMENT    OF 

shrinking  of  the  deposit  as  it  becomes  hardened  and 
thus  the  patient  may  go  through  life  with  a  fair  degree 
of  comfort. 

In  these  cases  of  spinal  involvement,  the  all-over 
electric  light  bath  is  a  most  valuable  addition  to  the 
treatment,  especially  in  cases  that  yield  with  difficulty 
to  the  treatments  as  outlined  above.  Where  this 
hypertrophic  type  involves  the  knee  joint,  in  the  cases 
that  have  come  under  the  writer's  observation,  it  is 
more  apt  to  be  accompanied  by  a  villous  arthritis. 
The  spurs  or  lipping  may  be  on  the  edges  of  the 
patella  or  on  the  edges  of  the  articular  surfaces  of 
either  the  tibia  or  femur.  These  overgrowths  may 
be  present  in  considerable  quantities  and  yet  not  be  in 
quite  a  location  to  interfere  mechanically  and  cause 
pain  and  tenderness.  In  such  a  knee  with  villus 
thickening,  it  is  the  boggy  and  swollen  condition  of 
the  membrane  which  causes  the  pain  and  discomfort, 
and  the  treatment  already  outlined,  —  that  is,  baking, 
vibration  or  wave  current,  and  sparking  with  the  gen- 
eral vibration  treatment  of  the  spine,  liver,  stomach, 
and  abdomen,  will  cause  the  slow  shrinking  and  disap- 
pearance of  the  congested  villi,  and  then  these  hyper- 
trophied  areas  will  give  no  trouble.  They  also  may 
shrink  some  and  the  patient  go  on  without  trouble. 
On  the  other  hand,  in  a  case  which  might  not  yield  to 
this  treatment  but  persist  in  causing  pain  and  tender- 
ness in  walking  or  going  up  or  down  stairs ;  or  in  a 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         35 

case  where  bone  formation  might  not  be  so  extensive 
but  in  such  a  location  as  to  interfere  mechanically 
and  cause  pain,  an  open  operation  would  be  necessary 
for  relief,  with  removal  of  the  swollen  and  thickened 
villi  and  also  of  the  spurs  of  bone. 

In  these  villous  conditions  which  really  come  to 
operation,  it  may  be  found  that  the  whole  joint  surface 
is  usually  completely  covered  with  this  swollen  and 
congested  villous  tissue.  It  is  completely  gorged  with 
blood  and  consequently  bleeds  very  freely  when  cut 
into.  This  cannot  be  curetted  off  as  the  sharpest 
curette  slips  over  it  without  removing  it.  It  must  be 
caught  up  with  forceps  and  cut  off  with  curved  scissors. 
In  this  way,  the  whole  joint  surface  must  be  thoroughly 
reached  through  two  longitudinal  incisions,  one  on 
each  side  of  the  knee.  The  supra  patella  pouch  must 
not  be  omitted.  Then  these  bony  spurs  must  be 
removed  and  the  knee  closed.  It  should  not  be 
splinted  or  placed  in  plaster  of  Paris  but  a  sterile 
dressing  applied  and  the  patient  will  then  bend  it  a 
little  when  moving  about  in  bed.  At  the  end  of  a 
week  or  ten  days,  walking  and  using  should  be  begun 
and  the  knee  baked  every  other  day,  and  passive  mo- 
tion utilized  every  day.  In  knees  where  an  extensive 
growth  of  these  villi  exist  and  the  inside  of  the  knee 
has  to  be  practically  skinned  to  completely  remove  it, 
forcible  moving  and  breaking  up  of  soft  adhesion  may 
be  necessary  once  or  twice  before  complete  motion  is 


36  THE    CLASSIFICATION    AND    TREATMENT    OF 

established.  In  such  cases  there  may  be  many  villi 
and  small  spurs  or  few  villi  and  many  spurs.  After 
recovery  from  operation,  it  is  very  important  to  go 
into  the  general  treatment  if  the  patient  will  do  so,  as 
it  is  the  general  process  (faulty  physiology)  which 
needs  treatment  in  order  to  prevent  future  trouble. 

Where  the  hip  joint  is  involved  with  this  overgrowth 
(morbus  coxas  senilis)  it  is  very  important  to  know  it 
as  early  in  the  process  as  possible.  The  hypertrophy 
may  exist  around  the  edges  of  the  acetabulum,  making 
the  socket  deeper  and  by  mechanical  blocking,  inter- 
fere with  the  extreme  range  of  motion.  The  same 
thing  results  if  the  growth  is  on  the  trochanter. 
Patients  are  very  apt  to  experience  difficulty  in  bend- 
ing over  to  lace  up  their  shoes  as  an  early  symptom. 
If  the  hypertrophy  takes  place  when  the  motion  of  the 
joint  mechanically  irritates,  it  is  better,  if  the  patient 
will  do  so,  to  use  crutches,  relief  thus  being  obtained 
from  the  aggravation  of  motion  with  the  body  weight 
upon  it.  Then  the  physiology  of  the  body  should  be 
stimulated  and  improved  by  eating  properly  as  already- 
described,  by  vibration  to  the  spinal  nerve  centres, 
liver,  abdomen,  and  lastly  to  the  hips.  Then  there 
should  be  a  fifteen  or  twenty  minute  treatment  with  a 
glass  vacuum  electrode  connected  with  a  high  frequency- 
coil.  This  stimulates  by  reason  of  the  action  of  the 
electricity  itself  and  a  marked  local  hyperemia  is  also 
produced.  In  this  way  a  marked  impression  may  be 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         51 

made  on  the  process.  If  allowed  to  go  on  untreated, 
the  bone  salts  are  laid  down,  going  through  the  process 
in  a  longer  or  shorter  time,  but  usually  years  rather 
than  months.  At  the  end  of  this  time,  the  motion  is 
very  apt  to  be  much  limited  mechanically,  and  in 
aggravated  cases  the  joint  is  completely  stiffened.  If 
the  diagnosis  is  only  made  early  and  the  patient  will 
submit  to  treatment,  this  course  may  be  very  much 
shortened  and  the  amount  of  the  deposit  reduced  to  a 
minimum  so  that  at  the  end,  the  limitation  of  motion 
may  not  be  great  and  walking  and  going  up  and  down 
stairs  not  much  interfered  with. 

The  process  is  the  same  in  any  joint  which  may  be- 
come affected.  The  fingers  are  often  involved  in  this 
type  of  trouble.  General  treatment  must  always  be 
instituted,  never  forgetting  that  the  joints  are  only 
external  manifestations  or  symptoms  of  the  general 
process.  This  means  general  vibration  to  spine,  liver, 
abdomen,  and  lastly  treat  the  joints.  In  the  fingers 
the  D'Arsonval  current  is  very  valuable  and  in  con- 
junction with  exposure  to  the  five  hundred  candle 
power  lamp,  will  very  markedly  relieve  pain,  thus  ren- 
dering splinting  unnecessary  and  also  causing  actual 
diminution  of  the  infiltration  of  the  soft  structures  if 
such  exists  as  it  usually  does.  The  surgical  removal 
of  these  spurs  is  called  for  when  they  mechanically 
interfere  with  movement.  The  knee  joint,  in  my 
experience,  is  the  most  often  treated  in  this  way.  The 
hip  joint  is  the  most  difficult  one  for  such  removal. 


38  THE    CLASSIFICATION    AND    TREATMENT    OF 

As  all  of  these  types  to  be  described,  with  the  excep- 
tion of  villous  arthritis  in  the  ankles  and  knees  which 
is  probably  due  to  mechanical  strain,  are  due  to  faulty 
physiology  and  hence  to  the  absorption  of  bacteria  or 
toxines,  they  might  all  be  placed  under  the  head  of  in- 
fectious arthritis,  but  it  is  a  decided  help  clinically  to 
have  the  different  types,  as  there  are  only  five  of  them 
and  as  it  is  usually  possible  to  differentiate  one  from 
the  other.  The  help  obtained  is  very  great  when  one 
has  to  examine  and  treat  a  considerable  number  of 
such  cases.  Under  infectious  arthritis,  as  it  has  been 
thus  far  classified,  are  included  cases  in  a  much  more 
active  stage  than  the  preceding  types  and  are  usually 
traceable  to  some  definite  infection.  The  joint  lesions 
may  be  due  to  the  poisons  of  the  bacteria  or  to  their 
toxines.  Perhaps  with  our  present  knowledge  and 
with  our  present  methods  of  examination,  it  would 
seem  that  most  of  the  cases  were  due  to  toxines  simply 
because  the  bacteria  are  usually  not  to  be  found. 
Probably  with  increased  knowledge  and  further  refine- 
ments in  technique,  the  bacteria  may  be  found  with  in- 
creasing frequency  either  in  the  fluid  or  the  surround- 
ing tissues.  In  a  case  from  some  active  infection,  the 
onset  is  usually  sudden.  Several  joints  will  be  involved, 
either  all  at  once  or  one  after  the  other  in  rapid  suc- 
cession. Most  of  them  will  clear  up  leaving  only  one 
or  two  finally  involved,  but  nevertheless,  the  condition 
is  manifestly  a  progressive   one.     In  both  cases,   the 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         39 

soft  structures  are  swollen,  spindle  shaped  around  the 
joints,  the  distention  causing  pain  either  from  the  dis- 
tension itself  or  from  pressure  on  the  nerves.  In  the 
acute  case,  it  is  severe ;  and  in  the  aggravated  type, 
there  is  delirium  from  the  septic  absorption.  In  the 
slower  type  there  is  usually  a  rapid  pulse,  even  though 
there  may  be  no  temperature,  thus  conveying  the  mes- 
sage of  a  septic  condition.  In  the  acute  type,  the 
organism  will  be  found  in  the  joint  fluid  and  anyway 
in  the  structures,  and  the  fluid  is  more  apt  to  be  pus 
and  the  destruction  of  structures  greater. 

For  treatment  to  be  applied  in  the  most  intelli- 
gent manner,  the  focus  of  infection  must  be  sought.  It 
cannot,  by  any  means,  always  be  found,  but  if  it  can, 
much  greater  good  can  be  accomplished.  In  a  chronic 
progressive  case  with  acute  exacerbations,  usually  fol- 
lowing tonsilitis,  it  is  fair  to  presume  that  the  tonsils 
are  the  focal  points  of  infection ;  and  in  such  a  case  the 
removal  of  these  organs  is  to  be  advised.  Many  times 
after  the  joints  are  restored  to  normal  condition,  there 
may  be  no  further  trouble.  This  would  demonstrate 
that  the  diagnosis  was  correct.  Septic  involvement  of 
the  joints  may  occur  in  any  of  the  infectious  diseases, 
—  typhoid,  scarlet  fever,  pneumonia,  grippe,  gonorrhea, 
etc.  If  due  to  toxines,  any  fluid  in  the  joints  will  prob- 
ably be  serum  while  if  the  organisms  are  present,  it  is 
more  likely  to  be  pus.  Toxic  joint  troubles  may  fol 
low  confinement  and  if  serious  blood  poison  be  present, 


40  THE    CLASSIFICATION    AND    TREATMENT    OF 

the  organisms  are  more  likely  to  involve  the  joints 
with  pus  formation.  This  toxic  sequence  is  more  apt 
to  result  in  some  paralysis.  Joint  involvement  in  a 
pneumonia  is  not  very  common,  but  it  does  happen. 
The  writer  has  observed  two  cases.  The  most  com- 
mon sequence  is  that  following  gonorrhea,  formerly 
called  gonorrheal  rheumatism.  If  the  organism  is  act- 
ually present,  the  result  is  more  apt  to  be  pus  and  the 
process  may  be  a  very  destructive  one.  In  acute  con- 
ditions of  joints  with  contractures  in  the  knees  where 
there  is  much  suffering  and  tenderness  and  excrucia- 
ting pain,  the  greatest  relief  may  be  obtained  by  fixa- 
tion in  plaster  for  a  few  days  only.  Then  it  may  be 
changed  when  it  will  be  found  that  the  knees  may  be 
placed  in  a  much  straighter  position.  Fixation  ought 
not  to  be  continued  for  very  long,  because  it  would 
tend  to  make  the  joints  stiff.  As  soon  as  the  plaster 
is  omitted,  appropriate  treatment  may  be  begun  at 
once. 

In  gonorrhea,  the  joints  may  become  involved  early 
or  late.  If  early,  it  is  fair  to  presume  that  the  organ- 
ism or  toxine  is  due  to  gonococci,  but  if  late  it  is  more 
than  apt  to  be  due  to  the  secondary  infection,  either 
streptococcus  or  stephylococcus.  A  gonorrheal  urethritis 
is  simply  a  discharging  sinus,  and,  like  all  such  sinuses, 
it  is  not  very  long  before  secondary  infection  takes 
place  and  the  joint  involvement  may  be  due  to  these 
organisms  or  to  their  toxines.     In  these  cases,  the  sem- 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         41 

inal  vescicles  sac  becomes  involved  and  then  as  the 
weeks  go  by,  this  sac  becomes  the  reservoir  continually 
distributing  some  of  its  store  of  poison.  In  this  con- 
dition the  joints  themselves  need  treatment  but  at  the 
same  time  this  focus  needs  the  utmost  attention  and 
this  will  be  first  discussed.  In  every  case  of  suspected 
gonorrheal  joints,  the  rectum  should  be  examined  to 
establish  the  condition  of  the  seminal  sac.  This  may 
be  much  enlarged  and  tender,  or  it  may  be  only  tender 
and  somewhat  more  tense  not  being  especially  en- 
larged. If  only  tenderness  exists,  it  is  usually  enough 
to  make  one  feel  pretty  certain  of  the  diagnosis. 
When  the  extreme  importance  of  this  focal  point  was 
appreciated,  stripping  (so-called)  was  employed.  This 
consisted  of  passing  the  finger  above  the  sac  (if  possi- 
ble), then  pressing  firmly  against  it  and  slowly  with- 
drawing, thus  mechanically  pressing  out  some  of  the 
contents.  Repeating  this  manoeuvre  several  times  the 
the  sac  was  emptied  to  some  extent,  and  keeping  it  up 
•every  other  day,  it  was  finally  supposed  to  remain 
empty  and  in  consequence  the  poison  ceasing  to  be 
distributed,  the  joints  would  slowly  get  well.  This 
was  true  in  some  cases,  but  not  in  the  great  majority 
of  them.  One  all  important  objection  to  this  method 
was  and  is,  that  in  most  men  the  finger  is  too  short  and 
that  it  does  not  quite  go  above  the  sac,  hence  there  is 
always  some  fluid  left.  The  positive  proof  of  this  lies 
in  the  fact  that  commercialism  attempted  to   remedy 


42  THE    CLASSIFICATION    AND    TREATMENT   OF 

this  by  offering  for  sale  an  extension  arrangement 
whereby  the  finger  was  made  longer.  This  also  was 
not  quite  satisfactory  because  the  sense  of  feel  could 
not  be  supplied  to  the  mechanical  extension.  The  next 
step  in  the  attack  upon  the  sac  was  made  by  Dr.  Fuller 
who  operated  by  the  perineal  route  and  drained  it. 
The  next  step  in  the  attack  is  the  most  efficient  of  all. 
It  is  not  nasty  like  stripping  and  is  not  disagreeable 
to  the  patient.  The  patient  is  placed  upon  his  side  on 
the  insulated  table  with  the  back  towards  the  static 
machine.  A  glass  vacuum  electrode  (Titus)  is  inserted 
into  the  rectum  with  the  concave  side  toward  the  sem- 
inal sac  and  connected  to  one  ball  of  the  machine,  the 
other  ball  being  grounded.  A  sufficient  amount  of  en- 
ergy is  generated  to  allow  of  a  four  to  six-inch  spark 
gap  between  the  balls.  Every  spark  across  these  balls 
means  a  surging  of  electricity  through  the  glass  vac- 
uum electrode  which  is  directly  against  the  seminal  sac. 
Every  blow  means  a  contraction  of  the  tissues,  thereby 
squeezing  out  the  infiltration  and  also  a  succession  of 
such  blows  means  an  emptying  of  the  sac  which  can 
be  demonstrated  by  finding  the  contents  in  the  ure- 
thral canal.  In  addition  to  this  is  the  marked  stimu- 
lating effect  of  the  electricity  upon  the  surrounding 
tissues  thus  toning  them  up  and  restoring  them  to  a 
normal  physiological  activity.  This  modality  also  ren- 
ders organisms  sterile  thus  causing  a  cessation  of  their 
ability  to  propagate.     This  is  far  and  away  superior  to 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         4o 

any  possible  effect  to  be  obtained  by  stripping.  The 
treatment  is  always  gauged  to  the  agreeable  tolerance 
of  the  patient  so  that  there  is  no  pain  attached  to  this 
part  of  the  treatment.  Any  urethritis  which  may  be 
present  should  also  receive  proper  treatment.  All  of 
the  various  injections  have  been  tried,  but  in  the  writ- 
er's hands,  the  most  efficient  of  the  injections  is  a  weak 
solution  of  AgN03.  (J  to  one  grain  to  6  ounces  of 
water).  This  the  patient  learns  to  do  himself  very  well, 
always  remembering  to  void  the  urine  just  before  inject- 
ing. Many  eroded  surfaces  which  resist  this  treatment, 
may  be  painted  locally  with  a  stronger  solution.  Stric- 
tures of  either  large  or  small  calibre  call  for  appropri- 
ate treatment,  and  a  word  about  these.  Strictures  of 
large  and  moderate  calibre  are  perhaps  still  best 
treated  by  "  sounds,"  but  the  small  ones  are  best  and 
most  efficiently  treated  by  galvanism.  It  is  much  bet- 
ter than  tearing  (divulsion)  or  cutting  as  both  of  these 
operations  result  in  scar  tissue  which  contracts  again, 
but  when  done  by  galvanism  there  is  no  scar  tissue, 
and  there  is  no  contraction  and  the  result  is  all  that 
could  be  desired.  Thus  the  urethra  is  treated  as  to  its 
calibre  and  urethritis  and  the  seminal  sac  emptied  and 
contents  rendered  sterile.  At  the  same  time,  this 
treatment  is  inaugurated,  the  joints  themselves  must 
be  attacked.  After  the  seance  with  the  glass  vacuum 
electrode  against  the  seminal  sac,  the  patient  may  be 
seated  upon  the  insulated  table  and  the  affected  joints 


44  THE    CLASSIFICATION    AND    TREATMENT    OF 

thoroughly  sparked,  using  the  spark  selector  (Snow). 
The  spark  gap  between  the  balls  must  be  such  as  to 
give  one-half  to  three-quarters  of  an  inch  spark  into 
the  tissue  thus  causing  tissue  contraction  and  thereby 
squeezing  out  the  inflammatory  products  into  their 
proper  physiological  channels  for  elimination.  All  of 
the  affected  joints  ought  to  have  a  thorough  sparking. 
If  one  or  two  are  particularly  tender,  a  few  minutes 
with  the  brush  discharge  will  often  give  great  relief. 
For  this  treatment,  the  patient  is  on  the  insulated  ta- 
ble connected  to  the  negative  side  of  the  machine 
while  the  positive  side  is  grounded.  The  balls  are 
widely  separated  while  the  operator  holding  a  pointed 
electrode  (either  metallic  or  a  wet  stick)  within  one  and 
one  and  one-half  or  two  inches  of  the  tissues,  a  fine  pur- 
ple spray  ma}^  be  seen  passing  between  the  tissues  and 
the  electrode.  This  brush  discharge  if  continued  steadily 
for  a  few  minutes  will  often  relieve  an  aching  joint. 
These  treatments  applied  from  a  high  frequency  coil 
are  not  the  same,  and  equally  good  results  cannot  be 
obtained.  In  cases,  where  ankles,  or  ankles  and  knees 
are  involved,  both  legs  may  be  thoroughly  bandaged 
up  to  the  groins  with  towels  and  placed  in  the  hot  air 
oven  for  one  hour  with  a  temperature  of  three  hundred 
to  three  hundred  and  fifty  degrees.  This  produces  a 
profuse  local  sweating,  thus  eliminating  some  products 
of  inflammation  locally  and  at  the  same  time  producing 
a  hyperemia  and  also  stimulating  the  circulation  and 


DISEASES    COMMONLY   KNOWN    AS    RHEUMATISM.         45 

nerve  supply.  If  baking  is  thus  employed,  the  joints 
should  be  thoroughly  vibrated  immediately  after  re- 
moval from  the  oven.  The  soft  brush  is  better  used 
about  the  ankle  joints  and  feet,  and  tendo  Achilles  and 
firm  pressure  employed.  The  knee  joints  are  better 
treated  with  the  hard  ball  as  deep  pressure  may  be  ex- 
erted and  almost  direct  contact  is  obtained  with  the 
thickened  and  infiltrated  soft  parts  and  the  villous  con- 
dition if  it  exists. 

Another  modality  may  here  be  made  use  of.  The 
glass  vacuum  electrode  connected  with  the  high  fre- 
quency coil,  may  be  used  for  ten  minutes  on  each  knee? 
producing  a  hyperemia  and  also  the  electricity  stimu- 
lating nerve  and  circulatory  supply.  While  speaking 
of  these  physical  methods,  one  method  of  treating  ure- 
thritis must  be  mentioned  because  it  is  perfectly 
scientific  and  must  of  necessity  be  more  and  more  used. 
In  a  beginning  gonorrhea,  when  the  inflammation  is 
confined  to  the  anterior  urethra  and  before  there  is 
any  secondary  infection  (in  other  words  entirely 
gonoccic)  the  process  should  be  quickly  controlled  and 
further  extension  prevented  in  the  following  manner. 
After  voiding  the  urine,  thus  thoroughly  washing  out 
the  urethra,  the  patient  is  placed  upon  the  insulated 
table  lying  on  the  back.  A  urethral  glass  vacuum 
electrodeps  inserted  and  connected  with  the  negative 
side  of  the  machine  for  the  first  few  treatments.  The 
positive  pole  is  grounded,  then  the  spark  gap  increased 


46  THE    CLASSIFICATION    AND    TREATMENT    OF 

up  to  the  agreeable  tolerance  of  the  patient,  perhaps 
two.  three,  or  four  inches.  The  treatment  should  be 
continued  twenty  minutes.  Connected  thus  with  the 
negative  pole  it  is  supposed  to  have  a  greater  effect  in 
rendering  the  organisms  sterile  and  so  not  capable  of 
propagating.  Two  or  three  treatments  daily  for  two 
or  three  days,  then  the  vacuum  electrode  might  be 
connected  with  the  positive  pole  of  the  machine.  Con- 
nected thus,  the  current  is  much  more  stimulating  and 
has  a  greater  effect  in  toning  up  the  parts  locally  and 
effecting  a  complete  restoration  to  a  normal  physiological 
condition.  In  this  manner,  it  will  be  readily  seen  that 
the  activity  of  the  organism  is  very  easily  destined 
and  secondary  infection  prevented  which  is  a  real  cure. 
Any  number  of  such  cases  have  now  been  treated  and 
with  unvarying  success.  A  recent  case  of  over  a 
year's  duration  where  the  ankles  and  knees  were 
especially  involved  with  an  active  urethritis  and  an 
enlarged  and  tender  seminal  sac  and  prostate,  a  half 
dozen  treatments  with  rectal  electrode  and  sparking 
have  done  for  the  patient  more  than  anything  pre- 
viously attempted. 

If  an  established  urethritis  complicating  a  gonorrhea 
or  (as  usual)  its  secondary  infection,  the  joints  may  be 
distended  with  fluid.  Usually  this  will  be  a  serous 
fluid.  This  may  be  at  once  aspirated  and  if  the  joint 
has  been  markedly  distended,  in  other  words,  if  there 
has  been  a  large  quantity  of  fluid  present,  it  may  be 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.        47 

put  in  plaster  of  paris  for  a  few  days  only  for  the  sake 
of  removing  the  irritation  due  to  the  constant  motion. 
It  should  after  a  few  days  be  removed  and  the  joint 
baked  every  other  day.  If  an  office  case,  and  vibration 
with  the  hard  ball  is  possible,  it  should  be  done  imme- 
diately after  baking.  If  the  amount  of  fluid  is  not  too 
large,  the  knee  may  be  bandaged  with  a  stockinette 
bandage  for  the  sake  of  compression  and  baking  should 
be  begun  immediately.  If  possible  the  baking  should 
be  followed  by  vibration  and  a  hypersemia  produced 
by  a  glass  vacuum  electrode  from  a  high  frequency 
coil.  In  an  acute  case  with  a  destructive  process 
advancing  rapidly,  the  joint  may  have  to  be  opened 
and  the  contents  evacuated.  The  joint  may  then  be 
washed  out  very  thoroughly  with  hot  saline,  spending 
twenty  minutes  or  more  when  it  may  be  possible  to 
close  the  operating  wound  tightly  and  treat  as  above 
described  with  no  further  trouble  from  the  active  pro- 
cess. Some  very  bad  cases,  have  behaved  very  nicely 
in  the  writer's  experience  when  treated  in  this  way. 
If  on  the  other  hand,  it  does  not  behave  well,  the  joint 
should  be  drained  through  and  through  so  that  every 
portion  may  be  very,  very  thoroughly  irrigated  daily  or 
twice  daily  until  the  infection  is  killed  out.  This 
infection  might  be  a  gonococcus  or  some  secondary 
infection.  As  such  a  case  slowly  recovers  (and  it  is 
generally  very  slowly),  the  joint  is  stiffened  by  adhe- 
sions and  there  will   be  a  tendency  to   contractures ; 


48  THE   CLASSIFICATION    AND    TREATMENT    OF 

hence  the  treatment  must  be  planned  to  prevent  these 
complications.     A  posterior  wire  splint  with  the  foot 
piece  at  right  angles  so  as  to  hold  foot  and  prevent 
contraction  of  the  tendo  Achilles,  and  extending  up  to 
the  fold  of  the  buttock  so  that  the  knee  may  be  placed 
in  a  completely  extended  position,  will  prevent  con- 
tracture.    Twice  daily  if  possible  this  splint  should  be 
removed  and  knee  and  ankle  manipulated  to  prevent, 
as  much  as  possible,  the  formation  of  adhesions  and  as 
soon  as  recovery  has  gone  on  far  enough,  the  knee  and 
whole  leg  may  be  baked  and  the  joints  manipulated 
immediately  after;  and  just  as  soon  as  the  patient  can 
be  moved  the  various  treatments  as  above  described 
should  be  instituted.     As  these  treatments  cannot  yet 
be  obtained  in   most   hospitals,   it   means    that   such 
patients  are  better  treated  and  recover  faster  as  soon 
as  they  can  get  to  the  office  where  such  things  are 
available.     The  finding  of  the  gonococci  in  the  joint 
fluid  is  rather  rare  although  it  must  be  present,  and 
would  probably,  if    put  through  the   guinea   pig,  be 
demonstrated.     If  not  found  in  the  fluid,  it  would  be 
more  apt  to  be  found  in  the  soft  tissues  around  the 
joint  if  in  an  open  operation,  some  were  taken  for  lab- 
oratory  examination.     A   recent   case    of    gonorrheal 
arthritis  under  the  writer's  care  had  fluid  in  both  knees 
and  the  gonococcus  was  actually  found  to  be  present 
in  the  fluid.     It  was  a  very  mild  case.     There    is    a 
marked  difference  in  the  virulence  of  the  organisms  in 
different  cases. 


DISEASES    COMMONLY   KNOWN    AS    RHEUMATISM.         49 

The  vaccine  treatment  has  been  left  until  the  last. 
It  has  been  demonstrated  by  Dr.  Wright  that  the 
opsonic  index  would  show  what  particular  infection 
was  causing  the  trouble ;  and  then  the  vaccine  should 
be  made  from  this  particular  organism  taken  from  the 
individual  (autogenous  vaccine),  this  to  be  followed  by 
subsequent  injections,  the  dose  to  be  graduated  accord- 
ing to  the  opsonic  index.  To  establish  this  index  and 
to  treat  each  time  in  accordance  with  it,  has  been 
found  impracticable  so  far.  Autogenous  vaccines, 
however,  may  be  used  without  going  through  all  this 
work.  In  gonorrheal  joints,  this  method  has  been 
used  by  various  workers  and  although  some  of  them 
(not  many)  report  that  the  results  are  encouraging,  if 
anyone  who  is  treating  a  considerable  number  of  such, 
joints  in  accordance  with  the  methods  above  given  will 
read  any  of  the  written  reports  of  vaccine  work,  even 
by  the  most  enthusiastic  of  its  exponents,  and  will 
carefully  analyze  the  results,  taking  into  consideration 
the  time  required  to  produce  these  few  results  reported, 
such  a  worker  will  find  these  results  when  compared 
with  his  own  very  disappointing  and  not  to  be  com- 
pared with  what  he  is  already  getting.  To  begin  with, 
scientific  workers  frankly  say  that  the  recognition  and 
isolation  of  the  gonococcic  bacillus  is  very  hard  and 
very,  very  disappointing.  This  throws  very  much 
doubt  on  some  other  workers  who  apparently  have  no 
such  difficulty.     This  alone  makes  the  preparation  of 


50  THE    CLASSIFICATION    AND    TREATMENT    OF 

an  autogenous  vaccine  in  this  particular  field  an 
extremely  uncertain  thing.  As  far  as  commercial  vac- 
cine is  concerned,  after  using  it  faithfully  on  a  line  of 
such  cases  in  hospital  (ward)  cases,  the  results  were 
absolutely  "  nil."  It  must  however  be  said  that  in  this 
experimental  work  absolutely  no  other  treatment  was 
used,  the  urethritis  itself  remaining  untreated  in  any 
other  way.  Thus  any  result  obtained  would  have  been 
due  to  vaccines.  There  are  cases  of  such  joint  involve- 
ment which  recover  very  quickly.  The  writer's 
experience  with  now  and  then  a  mild  case  with  a  mod- 
erate effusion  in  the  knee  joint  is  that  they  never  give 
any  further  trouble  after  a  single  aspiration  and  a  few 
bakings  (hospital  Avard  cases).  If  vaccines  (commercial) 
had  been  used,  the  result  might  have  been  attributed 
to  them.  Such  a  case,  by  the  way,  would  probably 
have  no  urethritis.  The  use  of  vaccines  then  in  the 
writer's  opinion  should  be  confined  to  autogenous,  and 
if  used  at  all  would  come  in  on  the  very  chronic  cases 
which  resist  all  treatment  and  then  should  be  used  in 
conjunction  with  some  of  the  other  methods.  In  such 
a  case  the  chief  and  crippling  infection  would  almost 
always  be  the  secondary  and  not  the  primary  or 
gonococcus.  Such  a  case  would  almost  always  be 
dependent  on  the  seminal  sac  and  the  treatment  should 
be  planned  to  attack  the  focal  point  as  well  as  the 
joints,  even  though  vaccines  should  be  used.  Some 
old  chronic  cases  of  this  type  are  very  resistant  to  any 


DISEASES    COMMONLY    KNOWN    AS    RHECJxMATISM.         5  ] 

and  all  kinds  of  treatment  and  no  method  can  yet 
report  one  hundred  per  cent  of  cures  to  say  the  least. 
An  extremely  interesting  case  of  such  a  type  presented 
itself  at  the  clinic  one  day.  Most  of  the  joints  of  the 
body  were  involved  and  had  been  for  many  months. 
A  careful  history  and  examination  revealed  infectious 
arthritis  with  a  chronic  urethritis  and  a  tender  and 
swollen  seminal  sac  and  enlarged  and  tender  prostate. 
The  patient  said  that  he  thought  he  knew  what  his 
trouble  was  much  better  than  almost  all  of  the  doctors 
whom  he  had  consulted  because  they  all  persisted  in 
calling  it  rheumatism  and  giving  him  medicines  which 
upset  his  stomach,  thus  spoiling  his  digestion  and 
doing  him  absolutely  no  good.  He  said  he  was  certain 
his  trouble  was  all  due  to  gonorrhea  and  that  treat- 
ment which  had  done  him  more  good  than  anything 
else  had  been  in  one  city  where  the  doctor  had  inserted 
in  the  urethra  a  glass  vacuum  electrode  and  gave  him 
electricity  in  this  way.  Here  was,  as  can  be  seen,  a 
case  of  gonorrheal  arthritis  and  only  one  man  out  of  a 
great  many  had  known  the  best  way  to  treat  it.  This 
corroborates  very  nicely  what  has  been  written  above. 
Infections  following  some  of  the  infectious  diseases 
are  also  still  called  rheumatism,  but  by  what  stretch  of 
the  imagination  it  is  impossible  to  know.  It  is  not  un- 
common for  the  grippe  to  create  joint  disturbance.  A 
recent  case  was  that  of  a  young  woman  who  had  an  at- 
tack of  the  grippe  and  on  the  second  or  third  day  the 


52  THE    CLASSIFICATION    AND    TREATMENT    OF 

wrist  and  hand  became  swollen,  tender,  and  painful. 
There  was  no  suppuration  so  that  it  must  be  put  down 
as  a  toxic  arthritis.  Another  case  was  that  of  a  woman 
who  in  November,  1909,  had  a  "  quinsy  sore  throat." 
It  was  not  opened  but  slowly  subsided  after  two  or 
three  weeks.  The  last  of  December,  1909,  or  first  of 
January,  1910,  there  was  an  attack  of  grippe  and 
early  in  the  disease  multiple  joints  were  involved. 
Each  of  these  cases  had  been  diagnosed  as  rheumatism 
but  of  course  in  the  light  of  a  careful  history,  such  a 
diagnosis  falls  to  the  ground. 

As  remarked  above,  pneumo-coccic  joint  involvement 
is  not  very  common.  A  recent  case  of  infectious  ar- 
thritis of  the  knee  following  a  pneumonia  is  very  inter- 
esting. The  process  became  so  destructive  and  the 
general  systemic  absorption  so  great  that  amputation 
became  necessary  as  a  life  saving  measure.  The 
stump  now  has  a  discharging  sinus  from  which  the 
pneumococcus  has  been  isolated  and  autogenous  vac- 
cines are  being  used  in  treatment,  but  so  far  with  no 
effect.  More  surgery  is  undoubtedly  in  sight.  The 
infectious  arthritis  which  is  most  common  is  one  where 
the  joints  have  been  involved  more  slowly,  with  acute 
exacerbations  at  intervals.  The  knees  or  fingers  or 
both  are  apt  to  be  involved  at  first,  and  as  the  process 
continues  the  joints  involved  become  more  and  more 
damaged  and  other  joints  become  attacked.  Sometimes 
the  very  first  beginning  of  the  trouble  may  be  an  acute 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         53 

attack  which  gives  the  appearance  of  being  an  acute 
articular  rheumatism,  but  it  either  subsides  in  all  the 
joints  with  a  not  quite  complete  recovery  or  else  the 
joints  subside  leaving  one  joint,  less  often  two,  as  the 
storm  centre  in  which  trouble  continues  and  demands 
careful  treatment.  In  the  acute  onset,  the  fever  is 
high  but  in  the  slowly  advancing  type  there  is  also  a 
temperature  and  an  increased  pulse  rate  showing  the 
systemic  septic  absorption.  When  all  other  avenues 
of  absorption  are  eliminated,  the  abdominal  viscera 
must  be  examined  carefully  as  it  is  from  these  that 
the  trouble  arises.  As  before  mentioned,  in  women 
more  especially  because  of  faulty  corsets,  the  abdomi- 
nal contents  are  pushed  downward  and  the  tighter  the 
lacing  and  smaller  the  waste  line,  the  greater  is  the 
sagging  tendency.  In  consequence  there  exists  a  back- 
ing up  of  the  intestinal  stream  with  its  fermentation 
and  formation  of  bacteria  and  toxines  and  absorption 
into  the  general  system  (systemic  poisoning),  and  lastly 
joint  (toxic  trouble).  Looked  at  in  this  larger  way, 
it  at  once  becomes  evident  that  salicyl  soda,  iodide  of 
potash,  colchicum,  etc.,  can  do  no  good  whatever.  Sal 
soda  and  aspirin  may  relieve  pain,  but  it  cannot  touch 
the  cause  of  the  trouble  except  as  it  may,  in  a  very  mild 
way,  be  an  intestinal  antiseptic.  Intestinal  antiseptics. 
Beta  Naphthol  and  Salol,  have  relieved  some  cases  but 
only  temporarily,  as  it  must  be  evident  with  the  above 
explanation  that  the  basic  reasons  still  exist  for  a  con- 


54  THE    CLASSIFICATION    AND    TREATMENT    OF 

tin  nance  of  faulty  digestion  and  faulty  assimilation. 
To  attack  this  condition  the  poison  already  in  the  sys- 
tem must  be  eliminated  and  its  manufacture  stopped. 
Both  of  these  objects  may  be  obtained  in  the  great  ma- 
jority of  cases  but  not  in  all  as  yet.  The  sagging  ten- 
dency may  be  limited  in  the  first  place  by  making  the 
corset  extension  (as  before  described)  so  that  it  shall 
support  the  abdominal  walls  from  the  umbilicus  to  the 
pubes,  thus  holding  up  (not  pressing  down)  the  abdom- 
inal contents.  An  important  thing  to  remember  in  ad- 
justing any  abdominal  support  to  a  corset  is  that  the 
middle  section  at  the  waist  line  must  be  a  little  looser 
than  the  lower  section  so  that  there  will  be  some  space 
for  the  viscera  to  go  when  they  are  raised.  Having 
thus  supported  the  abdominal  contents;  they  must  be 
stimulated  to  do  their  physiological  work.  In  the  first 
place,  what  is  put  into  them  must  be  prepared  in  a 
physiological  way  by  proper  mixing  with  saliva  as  de- 
scribed before.  Then  active  stimulation  may  be  best 
supplied  by  vibration.  The  hard  ball  on  the  spine 
stimulates  the  nerve  centres.  The  soft  brush  on  the 
stomach  and  intestines  and  the  hard  ball  on  the  ab- 
dominal lymphatics  stimulates  all  these  organs.  Let 
me  also  reiterate  that  the  liver  is  an  extremely  im- 
portant organ  standing  between  the  intestines  and  the 
general  circulation  to  filter  out  the  poisons.  This  is 
stimulated  in  a  wonderful  way  by  the  soft  brush  over 
the  liver  area,  front  and  back.     This  also  stimulates 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         55 

the  flow  of  bile.  It  is  truly  remarkable  at  times  to  see 
indigestion  of  both  stomach  and  intestines  which  have 
been  treated  with  no  benefit  by  the  best  of  medical 
men  in  probably  the  most  careful  (drug)  manner  slowly 
yield  and  get  entirely  well  and  also  the  joint  trouble 
improve  "  pari  passu."  Stimulation  applied  in  this 
manner  results  in  an  increased  tone  to  the  muscular 
walls  of  stomach  and  intestines  and  this  results  in  tak- 
ing up  of  the  slack  to  a  certain  extent  and  a  stronger 
muscular  activity  in  the  digestive  movements.  The 
various  fluids  are  also  in  this  way  stimulated  so  that 
they  are  secreted  more  copiously  and  more  rapidly.  In 
this  way  it  is  fairly  easy  to  understand  how  a  better 
and  better  "  tone "  is  obtained  and  how  a  more  and 
more  physiological  digestion  takes  place.  Hence  it 
must  also  result  in  a  diminution  even  to  complete  dis- 
appearance of  fermentation  and  formation  of  bacteria 
and  toxines.  In  cases  where  constipation  is  a  serious 
factor  in  the  backing  up  of  the  intestinal  stream,  al- 
though drugs  may  be  used  to  produce  evacuations,  the 
thing  to  be  desired  is  to  get  the  tone  of  the  muscular 
walls  so  improved  that  they  work  once  again  from  the 
stimuli  which  are  provided  in  nature's  own  way.  This 
will  be  spoken  of  again  in  the  section  on  the  X-ray 
study  on  abdominal  viscera  when  the  "  rationale  "  of 
the  treatment  will  be  shown  still  more  clearly.  This 
being  the  cause  and  the  cause  thus  removed,  the  con- 
sequent joint  trouble  must  disappear.   All  of  this  takes 


56  THE   CLASSIFICATION    AND    TREATMENT    OF 

time. —  in  many  cases  months.  And  at  the  same  time 
that  the  treatment  is  begun,  the  joints  themselves 
must  receive  attention  in  order  to  cause  the  swollen 
tissues  (infiltration)  to  become  contracted  and  restored 
to  a  normal  physiological  condition.  Elimination  must 
also  be  promoted.  Elimination  is  of  necessity  very 
markedly  improved  through  the  intestinal  canal,  and 
it  often  happens  that  an  obstinate  case  of  constipation 
is  cured  by  this  treatment  just  described.  This  means 
a  great  deal  by  way  of  elimination.  In  cases  where 
the  hot  air  baths  are  used,  usually  on  the  lower  ex- 
tremities, the  sweating  results  in  a  local  elimination  of 
toxines  through  the  skin. 

In  cases  where  multiple  joints  are  involved,  the  best 
results  are  obtained  by  the  all  over  electric  light  baths. 
The  effect  here  is  produced  by  radiant  heat  and  is 
one  of  marked  stimulation  to  the  whole  nervous  sys- 
tem. The  bath  used  by  the  writer  consists  of  a  hun- 
dred incandescent  lamps,  so  arranged  that  they  all 
throw  their  light  on  the  patient  who  lies  nude  upon 
a  couch.  All  these  lamps  are  in  circuit  with  a  regular 
theatre  dimmer  (rheostat)  so  that  all  the  lights  are 
going  all  the  time  and  the  intensity  may  be  graduated 
from  the  lowest  to  the  greatest.  As  the  rays  of  light 
impinge  upon  the  cutaneous  surface,  there  results  a 
stimulation  of  the  nerve  endings.  As  the  rays  of  light 
penetrate  different  structures  to  different  depths,  there 
is  a  point  where  each  ray  is  absorbed  and  at  this  point 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         57 

work  is  done,  just  the  nature  of  which  is  perhaps  not 
accurately  known.  Any  way,  at  the  point  of  absorp- 
tion the  energy  is  transmitted  to  the  living  cell  or  or- 
ganism, and  it  is  a  known  fact  that  the  result  is  a  stim- 
ulation in  such  a  way  that  the  local  processes  tend  to 
a  more  normal  condition.  A  first  bath  should  not  con- 
tinue for  much  more  than  ten  minutes.  Subsequent 
baths  may  be  longer,  up  to  twenty  minutes,  beyond 
which  it  should  almost  never  extend.  Toward  the  end 
of  the  bath,  sweating  begins  and  in  this  way  elimina- 
tion is  increased.  The  patient  is  in  the  bath  all  over, 
except  the  head  which  is  left  out.  It  is  of  great  im- 
portance to  keep  the  head  cool  by  an  ice  cap  or  elec- 
tric fan  or  both.  After  the  light  bath,  a  cool  water 
bath,  sponge  or  shower,  is  then  given  followed  by  a 
brisk  rubbing  with  a  turkish  towel.  This  leaves  the 
patient  feeling  fine.  The  general  vibration  treatment 
(as  before  described)  is  then  given  with  patient  lying 
upon  the  table.  By  these  methods  the  poisons  are 
eliminated  and  vibration  and  the  other  physical  meth- 
ods stimulate  the  physiological  processes  the  stomach 
and  intestines  being  stimulated  to  properly  perform 
their  work.  The  liver  is  also  stimulated  to  function- 
ate properly  with  the  result  that  bacteria  and  toxines 
cease  to  be  manufactured.  Lastly  the  tissues  around 
the  joints  are  stimulated  by  the  vibration  and  the  va- 
rious electric  modalities  as  above  described,  so  that  the 
infiltration  is  reduced  and  the  normal  in  size  and  struc- 


58  THE    CLASSIFICATION    AND    TREATMENT    OF 

ture  is  restored.  Whatever  damage  has  been  done  to 
cartilage,  by  way  of  destruction,  cannot  be  replaced, 
but  outside  of  this,  normal  conditions  can  be  restored 
very  largely. 

There  is  one  type  of  infectious  arthritis  which  has 
attacked  children  very  largely.  It  is  a  severe  infec- 
tion and  there  is  usually  glandular  enlargement  and 
the  spleen  is  apt  to  be  enlarged. 

This  was  first  described  by  Dr.  Still  and  hence  the 
name  Still's  disease  has  been  applied  to  it.  In  the 
light  of  modern  knowledge  and  in  accordance  with 
what  has  been  written,  this  condition  is  one  of  very 
definite  infection.  Any  one  who  has  followed  such  a 
case  medically  appreciates  that  the  disease  continues 
without  being  in  the  least  affected  by  the  so-called 
medical  treatment.  If,  however,  treatment  is  applied 
in  accordance  with  the  principles  just  elucidated  it 
will  be  found  that  the  disease  may  be  very  much  mod- 
ified in  its  course  and  the  patient  usually  put  upon  a 
solid  foundation  for  the  future. 

In  all  classifications  gout  has  a  place,  as  it  is  consid- 
ered a  disease  all  by  itself.  The  treatment  here,  as  in 
preceding  types,  should  be  in  accordance  with  the 
etiology.  Now  gout  has  for  years  been  treated  upon 
the  uric  acid  theory,  and  as  everybody  now  knows  uric 
acid  has  nothing  to  do  with  causing  it,  but  simply  is  a 
phenomenon  or  symptom  accompanying  an  attack.  In 
a  typical  case,  which  has  existed  for  a  sufficient  length 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         59 

of  time,  tophi  exist  in  the  ears  or  about  the  joints 
which  consists  of  urate  of  soda  deposits.  When  this 
stage  has  been  reached  the  diagnosis  is  easy,  but  in 
early  cases,  it  may  be  difficult  or  even  impossible. 
The  attacks  come  on  at  intervals  when  the  joint  or 
joints  are  swollen,  red  and  extremely  painful.  Joints 
may  become  thus  involved  following  an  acute  intestinal 
disturbance  and  they  might  also  be  the  result  of  auto- 
infection.  The  great  toe  joint  has  been  considered  es- 
pecially liable  to  attack,  but  any  joint  may  be  involved. 
It  is  simply  a  matter  of  history  in  such  cases,  that 
there  may  be  recurring  joint  attacks  and  attacks  fol- 
lowing acute  intestinal  disturbances  which  have  been 
called  gout,  but  as  the  years  go  by,  no  urate  of  soda 
deposits  appear  and  so  most  of  them  are  really  auto- 
infections  with  acute  exacerbations.  Take  the  cases 
that  are  finally  susceptible  of  positive  proof  as  gout. 
The  X-ray  studies  will  show  in  some  of  the  joints,  con- 
ditions typical  of  the  classes  just  described.  Hence  it 
is  fairly  demonstrated  scientifically  that  gout  is  due  to 
faulty  physiology  somewhere,  often  resulting  in  attacks 
of  acute  auto-infection.  The  following  is  a  case  in  the 
writer's  experience.  A  man  of  forty  had  a  second 
attack  of  infectious  arthritis  with  infiltration  of  the 
soft  structures  of  the  finger  joints  forming  the  spindle 
shaped  swelling  in  all  of  the  fingers.  An  X-ray  pho- 
tograph showed  the  bones  normal  and  the  process 
confined  to  the  soft  parts.     As  the  process  progressed 


60  THE    CLASSIFICATION    AND    TREATMENT    OF 

and  fluctuation  appeared,  the  fluid  was  aspirated  with 
a  hyperdermie  needle  and  the  microscope  revealed 
urate  of  soda  crystals.  Hence  a  true  case  of  gout  but 
clinically  an  infectious  arthritis  which  it  would  seem 
demonstrates  the  idea  above  expressed  of  faulty  phy- 
siology (metabolism)  and  auto-infection.  With  this 
description  the  treatment  to  be  logical  would  be  that 
just  described  under  infectious  arthritis  and  the  results 
of  treatment  would  completely  bear  this  out.  Elimina- 
tion of  poisons  induced  by  all-over  electric  light  baths, 
all-over  hot  air  baths  and  physiology  stimulated  by 
vibration  to  spinal  nerve  centres,  to  the  liver  area,  to 
the  stomach  and  abdomen,  and  lastly  to  the  local  tis- 
sues (joints)  stimulated  by  vibration  and  by  the  D'Ar- 
sonval  current.  The  method  of  eating  is  extremely 
important.  Add  to  this  physical  exercise  enough  to 
keep  the  weight  at  the  proper  point  and  future  attacks 
will  be  prevented.  One  method  of  treatment  where 
the  joints  are  painful  described  by  French  writers  is 
the  ionic  treatment,  that  is  sending  in  the  ion  of  Lithium 
by  means  of  the  constant  current.  A  small  bath  tub 
for  the  feet  or  hands  according  to  the  case,  is  prepared 
with  the  following  proportions :  Chloride  of  Lithium, 
20  grams;  distilled  water,  1000  cc,  and  sufficient  caus- 
tic Lithium  to  render  alkaline.  This  solution  is  con- 
nected by  carbon  electrodes  to  the  positive  pole  of  the 
constant  current.  Another  large  carbon  electrode, 
covered   with    twenty-four   or    thirty    thicknesses    of 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         61 

gauze  saturated  with  saline  solution,  is  bandaged  in 
close  contact  with  the  skin  on  the  back  of  the  neck,  or 
some  neutral  point,  and  connected  with  the  negative 
point  of  the  source  of  supply.  The  current  is  then 
slowly  turned  on  until  it  is  one  hundred  and  fifty  or 
two  hundred  milliamperes,  the  seance  continuing 
thirty  to  forty-five  minutes.  The  ion  of  Lithium  is 
thus  driven  into  the  tissues  of  the  affected  joints  and 
there  is  formed  a  urate  of  Lithium  which  is  very  sol- 
uble. These  seances  are  repeated  three  times  weekly 
and  should  be  followed  by  an  alleviation  of  the  pain 
with  diminished  suffering  and  disappearance  of  the 
attack.  This  method  gave  relief  and  cure  of  the  attack 
in  the  case  referred  to  above  and  an  alleviation  of 
symptoms  in  one  other  case. 

Early  in  the  paper  the  method  of  eating  was  discussed 
and  now  a  word  regarding  what  kind  of  foods  to  eat. 
In  former  times  a  great  deal  was  written  about  not 
eating  meat  and  restricting  the  diet  very  markedly. 
This  was  an  error  which  in  the  light  of  more  modern 
investigation  has  been  corrected.  An  editorial  writer 
in  the  Journal  of  the  American  Medical  Association  for 
November  30th,  1907,  says :  "  It  is  striking  that  the 
laying  up  in  the  body  of  proteins  is,  save  in  the  grow- 
ing young,  accomplished  only  under  exceptional  con- 
ditions and  that  the  body  seems  to  have  no  such  place 
for  the  storage  of  proteins  as  it  has  for  fats  and  car- 
bohydrates.    The  amount  of  breaking  down  and  build- 


62  THE    CLASSIFICATION    AND    TREATMENT    OF 

ing  up  of  tissue  cells  that  we  can  detect  seems  to  be 
far  too  small  to  account  for  the  amount  of  proteins 
that  is  required  and  yet  so  far  as  we  know,  this  is  the 
only  purpose  for  which  proteins  are  indispensable. 
We  know  that  the  characteristics  of  different  cells  and 
tissues  depend  chiefly  or  solely  on  their  proteins  and 
the  proteins  in  turn  differ  from  one  another  in  the 
proportion  of  the  various  constituent  amido  acids  that 
they  contain.  Each  class  of  animals  has  cellular  por- 
teins  and  blood  proteins  specific  for  its  own  kind  as 
shown  by  precipitin  tests  and  it  is  possible  that  the 
proteins  of  every  individual  differ  in  some  respects 
from  those  of  every  other  individual.  Consequently 
the  conversion  of  the  multitudinous  varieties  of  pro- 
teins taken  with  the  food  into  the  constant  proteins  of 
the  individual  cells  must  require  a  most  complete 
reconstruction  of  the  food  proteins.  In  the  intestines 
the  proteins  are  split  into  their  elementary  constituents, 
the  amido  acids,  through  the  action  not  only  of  the 
trypsin  but  especially  by  the  erepsin  of  the  intestinal 
mucosa.  These  amido-acids  are  resynthesized  into 
proteins  and  it  seems  probable  that  this  process  is 
accomplished  by  the  cells  of  the  intestinal  walls  and 
the  proteins  resulting  are  those  that  are  found  in  the 
blood  serum.  The  excess  in  amido  acids  that  are  fur- 
nished in  this  way  by  the  food  and  which  cannot  be 
used  by  the  organism  for  the  building  up  of  its  own 
type  of  proteins  are,  it  is  believed,  deprived  of  their 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         63 

nitrogen  by  the  action  of  certain  enzymes  and  the 
nonnitrogenous  residue  may  then  be  available  for  fur- 
nishing heat  and  energy.  By  this  means  the  cells  are 
provided  by  the  blood  with  protein  supplies  of  prac- 
tically constant  composition  and  the  intestinal  wall 
may  be  looked  on  as  the  guardian  of  the  chemical 
specificity  of  the  individual.  In  this  case  it  is  easy  to 
imagine  that  the  intestinal  wall  might,  under  certain 
conditions,  be  unable  properly  to  synthesize  serum 
proteins  and  from  this  might  result  serious  disturbances 
in  general  metabolism.  It  will  be  seen  from  this 
description  that  there  goes  on  in  the  intestinal  wall  a 
selective  synthesis  by  which  proteins  and  the  serums 
are  utilized  by  the  different  cells  of  the  body  since  the 
proteins  of  these  cells  contain  proportions  of  the 
various  amido  acids  different  from  those  of  the  serum 
proteins.  In  the  light  of  this  kind  of  physiology,  it  is 
at  once  evident  that  the  ordinary  metabolism  experi- 
ments are  erroneous  and  that  it  is  the  mixed  diet  of 
the  table  that  is  most  advantageous  for  the  deficiencies. 
Certain  amido  acids  of  one  protein  may  be  replaced  by 
a  relative  excess  of  the  same  amido  acids  in  some  other 
protein." 

This  shows  the  importance  of  the  intestinal  wall  and 
the  extreme  importance  of  keeping  up  to  normal  its 
physiological  activities  and  also  demonstrates  the  fact 
that  the  diet  must  be  a  mixed  one,  also  that  as  the  old 
idea  demands  that  there  must  be  restriction  in  one 


64  THE    CLASSIFICATION    AND    TREATMENT    OF 

direction  and  greater  liberty  in  another,  there  must 
result  a  disarrangement  of  the  stream  which  is  con- 
stantly supplying  the  demands  all  along  its  course. 
Hence  it  is  pretty  conclusively  proven  that  the  mixed 
diet  in  eating  as  already  described  is  the  proper  phy- 
siological thing.  If  this  is  done  not  only  will  less  meat 
be  eaten,  but  less  of  everything  will  be  eaten  to  the 
permanent  benefit  of  the  individual. 

After  discussing  these  classes  of  joint  trouble  and 
their  logical  treatment,  it  must  not  be  forgotten  that 
there  is  as  yet  an  acute  inflammatory  articular  joint 
trouble  which  still  remains  as  an  entity  and  called 
acute  rheumatism.  It  has  been  claimed  that  a  bacillus, 
called  the  rheumatic  bacillus,  has  been  isolated  and 
similar  joint  disturbances  produced  by  injecting  the 
same  into  animals ;  but  these  experiments  have  not 
been  duplicated  and  so  it  is  probably  an  infectious 
arthritis  with  the  organism  not  yet  proved.  Anyway 
the  disease  involves  the  joints,  two  or  three  being 
attacked,  then  others  becoming  involved  in  turn,  and 
when  the  last  are  attacked  the  first  ones  are  apt  to 
have  subsided.  This  disease  runs  its  course  in  four, 
six,  or  eight  weeks  and  there  should  be  complete 
recovery.  If  one  or  more  joints  remain  not  quite  com- 
pletely recovered,  it  means  that  in  due  course  of  time 
there  may  be  another  attack  or  that  this  initial  explo- 
sion is  to  be  followed  by  gradual  progressive  involve- 
ment of   other  joints.     In  other  words  this  condition 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         65 

would  then  fall  under  one  of  the  classes  just  mentioned, 
that  is  infectious  arthritis.  In  a  typical  attack  of  the 
acute  type,  or  acute  articular  rheumatism,  it  is  a  well- 
known  fact  that  salicylates  have  a  wonderful  effect 
upon  pain  and  temperature,  but  in  hospital  (ward) 
cases  a  much  more  beneficial  effect  has  been  obtained 
by  the  writer  when  the  patient  was  put  into  an  all- 
over  hot  air  bath  which  was  followed  by  a  gentle  rub- 
bing. It  is  remarkable  to  see  pain  relieved  in  this  way 
in  a  very  few  minutes  when  it  would  require  hours  if 
the  salicylates  were  depended  upon.  If  salicylate  or 
aspirin  are  used  it  must  not  be  forgotten  that  the  heart 
is  much  depressed  and  needs  stimulation.  If  the  case 
is  in  a  private  house  the  hot  water  (tubj  bath  is  a  fairly 
good  substitute  for  the  hot  air.  The  patient  may  be 
gently  laid  in  the  tub  in  just  warm  water,  then  the  hot 
water  allowed  to  slowly  flow  in.  The  first  bath  should 
be  only  fifteen  or  twenty  minutes,  and  perhaps  never 
more  than  one-half  or  three-quarters  of  an  hour.  Con- 
tractured  joints  will  slowly  straighten  and  pain  disap- 
pear in  a  most  gratifying  manner.  In  the  acute  stage 
this  may  be  repeated  two  or  three  times  daily,  the  last 
one  being  given  in  the  evening,  and  the  patient  all 
wrapped  up  warmly,  and  it  is  surprising  to  see  them 
sleep  fairly  well  without  narcotics  or  salicylates.  With 
recovery  setting  in  contractures  must  be  avoided  by 
gentle  massage  and  manipulation  and  even  splinting  or 
plaster  for  a  very  short  time  if  necessary. 


6(5  THE    CLASSIFICATION    AND    TREATMENT   OF 

Faulty  physiology  of  the  intestines  has  already  been 
referred  to  and  sagging  of  all  the  viscera  and  the  im- 
portance of  their  support  by  an  abdominal  belt  men- 
tioned. X-ray  studies  of  the  position  and  malposition 
of  the  abdominal  contents  have  been  made  by  various 
X-ray  workers.  I  will  not  give  all  of  their  work  but 
simply  refer  to  the  works  of  two  or  three  because  they 
happen  to  cover  the  points  which  are  of  importance  in 
this  paper.  Dr.  Henry  K.  Pancoast  contributed  a 
paper  entitled  "A  Study  of  Gastroptosis  from  the  Rad- 
iographic Standpoint"  in  International  Clinics,  vol.  4, 
17th  series:  and  Dr.  G.  E.  Pf abler  contributed  an 
article  entitled  "  Physiological  and  Clinical  Observa- 
tions on  the  Alimentary  Canal  by  means  of  the  Roent- 
gen Rays"  in  the  Journal  of  the  American  Medical 
Association,  December  21st,  1907;  and  Dr.  Guido 
Holzknecht  also  contributed  a  very  interesting  article 
entitled  "  The  Normal  Peristalsis  of  the  Colon "  in 
Miinchiner  Medizinische  Wochenschrift  for  November 
23rd,  1909.  Regarding  the  sagging  of  the  abdominal 
viscera  the  above  writers  with  many  others  have  con- 
tributed some  valuable  X-ray  studies  showing  that 
these  organs  occupy  quite  different  positions  normally, 
than  anatomists  have  thought.  Pancoast  and  Pf abler 
show  that  the  stomach  might  be  anywhere  in  the 
anterior  portion  of  the  abdomen  from  above  the  urn- 
bilicis  to  a  position  practically  resting  on  the  pubes. 

The  article  of  Dr.  Pancoast  has  sixty-seven  figures 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM. 


67 


showing  different  positions  of  the  viscera.    Only  three 
of  his  diagrams  will  be  reproduced. 


Figure  19. 


Fig.  1.  —  This  shows  Dr.  Pancoast's  idea  of  the  nor- 
mal stomach,  but  in  the  light  of  studies  of  my  own  in 
healthy  children  I  should  consider  this  too  high. 


68 


THE    CLASSIFICATION    AND    TREATMENT    OF 


Fig.  15.  —  This  shows  the  ptosis  of  the  stomach, 
liver  and  also  the  spleen. 

Fig.  19.  —  This  shows  in  addition  to  the  ptosis  of 
the  other  organs  an  extreme  ptosis  of  the  transverse 
colon. 


The  above  is  a  drawing  made  from  Dr.  Pfahler's  re- 
production and  shows  his  idea  of  the  normal  position 
of  the  stomach  and  intestines. 

Pfahler  considers  that  in  a  normal  stomach,  the  pyl- 
orous  is  about  one  inch  above  the  umbilicus  and  what 
seems  to  be  very  logical,  also,  that  it  is  not  so  much 
the  position  of  the  stomach  as  the  motility.  In  other 
words,  if  the  organs  are  performing  their  functions 
properly,  there  should  be  no  symptoms,  but  it  is  under 
these  conditions  that  dilatation  and  atony  takes  place 
and  that  trouble  begins.  It  is  also  in  these  conditions 
that  the  stimulation  and  toning  up  is  accomplished, 
so  much  more  effectively  by  the  methods  before  de- 
scribed (physical  therapeutics)  than  by  medication. 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         69 

The  important  lesson  to  be  learned  from  these  X-ray 
studies,  however,  is  that  the  position  of  the  abdominal 
viscera  is  different  in  the  living  than  .we  have  been 
taught  from  the  dissection  on  the  cadaver  and  from 
the  recognized  books  on  what  might  be  called  "  dead  " 
anatomy.  Now  with  the  coming  of  "living"  anatomy 
as  shown  actually  "in  situ"  by  the  X-ray  it  is  an  en- 
tirely different  proposition.  As  will  be  noticed  in  the 
figures  of  Pancoast  and  Pfahler  the  stomach  is  more 
nearly  straight  up  and  down  hanging  in  the  anterior 
part  of  the  abdomen  like  a  bag  and  hanging  very  much 
lower  than  there  was  any  idea  of,  the  normal  position 
being  down  near  the  upper  level  of  the  pelvis  (ilia). 
This  position  which  at  first  seems  to  be  away  down  at 
the  bottom  of  everything  must  be  now  recognized  as 
a  "  new  "  and  "  living  "  normal.  The  transverse  colon 
and  the  "flexures"  also  become  drawn  or  pushed 
downward  and  it  would  seem  thus  far  in  the  new  X-ray 
study  of  these  conditions  that  the  colon  is  really  more 
displaced  from  normal  than  the  stomach.  In  all  these 
cases  unless  there  is  a  marked  displacement  it  would 
seem  that  Pfahler' s  conclusions  were  the  correct  ones, 
that  it  is  not  so  much  the  ptosis  of  the  organs  as  it  is 
their  motility.  In  other  words  if  the  physiological 
work  of  these  organs  is  all  right  a  certain  amount  of 
leeway  may  be  allowed  regarding  their  position.  In 
sagging  organs  there  is  more  or  less  atony  and  conse- 
quent sluggishness  of  action,  and  then  the  important 
thing  is  to  so  stimulate  them  that  such  action  may  be  re- 


70  THE    CLASSIFICATION    AND    TREATMENT    OF 

stored.  It  is  just  this  problem  that  must  be  solved  and 
that  is  at  the  bottom  etiologically  in  chronic  joint  diseases. 
The  paper  contributed  by  Holzknecht  is  the  latest 
and  most  important  communication  regarding  the 
intestines  and  their  method  of  action.  I  am  simply 
repeating  nearly  verbatim  a  part  of  his  extremely 
interesting  message.  He  calls  attention  to  the  fact 
that  radioscopy  has  shown  that  peristalsis  of  the 
oesophagus  consists  in  an  annular  contraction  some 
centimeters  in  length  which  follows  the  contraction  of 
the  pharanx  and  forces  the  bolus  along  the  course  of 
the  gullet,  also  that  the  normal  peristalsis  of  the  fun- 
dus and  the  antrum  and  a  terminal  contraction 
(pylorus).  The  chyme  in  the  small  intestine  is  also 
propelled  by  a  series  of  short  jerks.  Then  he  has  per- 
sonally observed  the  abdominal  viscera  in  over  one 
thousand  fluoroscopic  examinations  and  with  two 
exceptions  has  always  found  the  large  intestine  immo- 
bile. In  these  two  cases,  however,  twenty-four  hours 
after  a  bismuth  meal,  the  following  interesting  phenom- 
enon took  place.  The  segmentations  in  the  transverse 
colon  disappeared,  the  outlines  of  the  intestines  becom- 
ing perfectly  smooth  like  a  ribbon  with  parallel  bor- 
ders and  the  contents  were  with  equal  rapidity  forced 
forward  into  the  descending  colon  which  had  been  pre- 
viously empty.  The  time  occupied  in  this  whole  move- 
ment was  estimated  at  about  three  seconds.  Just  as 
soon  as  this  transference  was  completed  the  h austral 
segmentation  reappeared  and  the  transverse  colon  re- 


DISEASES    COMMONLY    KNOWN    AS    KMKUMATISM. 


71 


mained  empty.  The  patient  was  entirely  unaware  of  any 
movement.  Experiments  in  Holzknecht's  hands  show 
that  kneading,  massage,  etc.,  had  no  effect  in  the  loco- 
motion of  the  intestinal  contents,  while  on  the  other  hand. 
Groedel  has  observed  that  vibratory  massage  hastens 
the  progression  of  the  contents.  Normally  this  move- 
ment, involving  about  one-third  of  the  intestine  each 
time,  takes  place  about  three  times  in  twenty-four  hours. 
In  the  interim,  it  is  held  in  the  haustral  segmentation 
perfectly  immobile,  where  absorption  takes  place. 


Figure  3. 


Figure  4. 


72  THE    CLASSIFICATION    AND    TREATMENT    OF 

Drawings  made  from  Holzknecht's  figures  are  also 
here  reproduced. 

Fig.  1.  This  shows  (24  hours  after  the  bismuth 
meal)  the  colon  completely  rilled,  up  to  the  splenic 
angle.  The  sigmoid  flexure  is  also  completely  filled 
and  all  of  these  portions  when  observed  in  the  fluoro- 
scope  are  immobile. 

Fig.  2.  —  This  shows  the  observation  when  the  seg- 
mentations in  the  transverse  colon  suddenly  disap- 
peared and  the  intestine  flattened  out,  the  ascending 
colon  remaining  the  same. 

Fig.  3. — This  shows  the  observation  when  the 
transverse  colon  had  been  suddenly  emptied  into  the 
descending  colon  and  then  as  in  Fig.  4,  the  haustral 
segmentations  immediately  reappeared  in  the  whole 
length  of  the  intestine  at  the  same  instant. 

All  of  this  throws  light  on  so-called  faulty  physiology 
with  the  sagging  or  ptosis  of  abdominal  viscera,  its 
resulting  atony  and  interference  with  intestinal 
mobility,  first  causing  fermentation,  bacteria,  toxines, 
and  absorptions,  with  consequent  joint  involvement. 
This  is  of  importance  in  constipation.  This  sudden 
transference  of  the  intestinal  contents  of  one  section 
to  another  may  be  the  normal  mechanism ;  and  if  so, 
further  study  will  demonstrate  it.  While  the  intestine 
remains  immobile  with  the  contents  held  tightly  in  the 
haustral  folds,  the  juices  of  the  intestine  are  given  out 
and  at  the  same  time  whatever  is  of  value  in  that  parti c- 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         73 

ular  stage  of  digestion  is  absorbed.  When  the  intestine 
suddenly  straightens  out  and  the  contents  are  forced 
along,  it  must  be  done  by  muscular  contraction,  and 
this  muscular  contraction  takes  place  as  the  direct  result 
of  some  physiological  stimulus.  This  stimulus  may  be 
due  to  a  certain  degree  of  osmosis  which  has  taken 
place  or  the  attainment  of  a  certain  chemical  reaction 
due  to  a  certain  stage  of  osmosis.  Hence  it  is  that 
vibratory  massage  to  the  spinal  nerve  centers,  to  the 
abdomen,  and  to  the  muscular  walls  themselves  is  a 
much  more  rational  measure  than  massage  or  medi- 
cation. This  is  borne  out  by  the  actual  results  of 
treatment.  This  does  not  mean  that  cathartics  are 
no  longer  necessary.  But  it  does  mean  that  it  is  a 
very  logical  treatment  to  get  the  entire  physiology 
to  working  properly. 

Another  important  thing  along  nature's  lines  is 
physical  exercise.  In  many  of  these  chronic  joint  dis- 
ease cases,  especially  in  women  who  are  inclined  to  be 
stout  with  the  fat  tissue  predominating  around  the  hips 
and  on  the  abdomen,  physical  exercise  will  reduce  the 
fat  in  these  areas ;  and,  if  the  weight  is  kept  down 
below  a  certain  point,  the  patient  may  remain  perfectly 
free  from  joint  trouble.  The  exercises  should  be  given 
always  at  the  office  gymnasium  under  competent 
supervision,  and  those  to  be  preferred  are  in  the 
abdominal  chair  which  directly  calls  into  use  the 
muscles  of  the  legs  and  abdomen,  similar  to  bicycle 


74  THE    CLASSIFICATION    AND    TREATMENT    OF 

riding.  The  rowing  machine  is  another  excellent 
exercise.  Standing  erect  with  arms  by  the  side  and 
chest  expanded  and  alternately  pulling  up  the  lower 
abdomen  by  voluntary  muscular  exertion  and  allowing 
it  to  sag  again,  standing  erect  with  arms  extended  over 
the  head,  then  stooping  over  forwards  and  touching 
the  toes  with  the  tips  of  the  fingers  while  the  knees 
are  held  straight,  are  excellent  movements  which  assist 
in  removing  fat  from  the  abdomen.  The  heart  is  to 
be  looked  out  for  and  the  patient  watched  and  not 
very  much  in  the  way  of  exercise  done  at  home 
especially  in  older  adults,  otherwise  damage  will  result. 
The  important  rule  is  that  all  this  work  should  be 
done  under  competent  medical  supervision. 

It  is  along  physiological  (nature's)  lines  that  treat- 
ment should  be  administered  in  the  chronic  joint  dis- 
eases. It  means  building  upon  a  perfectly  safe  and 
solid  foundation  and  then  instructing  patients  how  to 
keep  themselves  in  proper  condition  by  methods  of 
right  living,  in  this  way  insuring  them  perfectly 
against  not  only  the  joint  diseases  under  discussion  but 
probably  against  all  chronic  diseases  outside  of  malig- 
nant diseases  and  infection  introduced  from  without. 

As  a  result  of  this  work  it  will  be  seen  that  the  types 
now  pretty  generally  recognized  are  those  originally 
described  by  Goldthwait  but  the  writer  would  classify 
them  a  little  differently. 

Gout  is  very  definitely  shown  to  be  due  to  faulty 


DISEASES    COMMONLY    KNOWN    AS    RHEUMATISM.         75 

physiology  and  hence  comes  under  auto-infection  or 
auto-intoxication. 

Also  in  the  observation  of  a  number  of  cases  of  atro- 
phic arthritis  which  have  remained  such  for  years,  it 
has  been  observed  that  attacks,  (very  mild  at  first) 
come  on,  where  the  swelling  takes  place  only  to 
shortly  disappear,  then  later,  redness  and  permanent 
infiltration  of  soft  structures  with  a  more  rapidly  pro- 
gressing process,  thus  placing  this  type  also  under 
auto-infection  or  auto-intoxication. 

Hence  the  classification  most  satisfactory  to  the 
writer  is  the  following :  — 

Villous  Arthritis 

.      .  >.  f  Atrophic  Arthritis 

Auto-miection  i  , .     *    i    ■  • 

I    Hypertrophic  Arthritis 

i   Infectious  Arthritis 


Auto-intoxication   J 


[  Gout 


Fig.  1  and  2  is  the  same  knee  showing  the  calcified 
tips  of  the  villi  "in  situ"  and  also  after  removal. 

Fig.  3  shows  an  atrophic  arthritis  in  which  the  car- 
tilage is  atrophied,  but  it  is  to  be  noted  that  the  bone 
salts  have  been  washed  out  so  that  the  bones  appear 
very  thin. 

Fig.  4.  A  normal  knee  is  presented  for  contrast 
with  Fig.  5  in  which  joint  the  cartilage  is  atrophied  so 
that  the  bones  are  in  actual  contact. 

Fig.  6  shows  a  later  stage  of   the    atropic  process 


76       CLASSIFICATION  AND  TREATMENT  OF  RHEUMATISM. 

when  the   cartilage    has   practically   disappeared    and 
bony  anchylosis  has  actually  taken  place. 

Fig.  7  shows  the  overgrowth  of  bone  or  hypertrophy 
at  the  upper  border  of  the  patella  and  also  along  the 
edges  of  the  joint  surface  of  the  fermur. 

Fig.  8  shows  the  two  rows  of  joints  in  the  lingers 
with  the  cartilage  atrophied  and  bone  destruction 
taking  place.  In  the  terminal  joints  the  lipping  of  the 
bone  at  the  sides  is  apparent,  thus  showing  the  mixed 
type. 

Fig.  9  is  the  picture  from  a  demonstrated  general 
infection  with  multiple  joint  involvement. 

Fig.  10  shows  the  ultimate  stage  in  an  infectious 
arthritis. 

Fig.  11  shows  a  wrist  joint  involvement  from  a  gon- 
orrhoea. 

Fig.  12  is  interesting  when  compared  with  Fig.  14, 
a  gouty  elbow,  and  also  that  one  of  the  joints  might 
be  considered  (from  the  X-ray  alone)  a  Charcot  joint, 
but  here  again  is  a  case  of  known  infection. 

Figs.  13,  14,  and  15  are  all  from  one  patient  who 
has  a  (demonstrated)  gout.  There  were  tophi  in  the 
ears  and  he  could  write  on  the  blackboard  with  the 
fingers,  there  was  so  much  urate  of  Soda  deposited  in 
crystals. 

Fig.  16  was  also  a  demonstrated  case  of  Charcot 
joint  in  a  man  suffering  from  Tabes. 


Fig.  i.    Villous  Arthritis. 
Showing  calcined  tips  of  villi. 


i '  -1  * * 

1    ••"     ♦    * 

1.  -  * 

*  ^  **4 

f 

,;  i  **  *   l  j 

L.  *  '41 

& 


m  <•£ 


"C 


— 


u 


<: 


Fig.  4.     Normal  Space  in  Normal  Knee  Joint. 


Fig.  5.    Atrophic  Arthritis. 
Demonstrated  by  diminution  of  space  between  bones. 


z    - 

.     v. 


Fig.  7.    Hypertrophic  Arthritis. 


Fig.  8.     Atrophic  and  Hypertrophic  Arthritis. 
Mixed  type. 


05 


0\ 


Fig.  io.    Ankylosis  of  the  Knee  Joint  Following 
Infectious   Arthritis. 


Fig.  15.    Gouty  Knee. 


Fig.  16.     Charcot  Joint. 


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The  classification  and 
treatment  of  diseases  com- 
monlv  known  sr   r<Vianmo+ip» 


Annex 


/7/0 


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